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A 


PRACTICAL  TREATISE 


GENITOURINARY  AND  VENEREAL 
DISEASES  AND  SYPHILIS. 


BY 

ROBERT   W.  TAYLOR,  A.M.,  M.D., 

CLINICAL  PROFESSOR  OF  GENITO-URINARY  DISEASES  AT  THE  COLLEGE  OF  PHYSICIANS  AND  SURGEONS 

(COLUMBIA  UNIVERSITY),    NEW   YORK  ;    CONSULTING    GENITO-URINARY  SURGEON    TO 

BELLEVUE   HOSPITAL    AND  TO  CITY  (CHARITY)  HOSPITAL,  NEW  YORK. 


THIRD  EDITION,    THOROUGHLY  REVISED. 


WITH   163  ILLUSTRATIONS  AND  39  PLATES  IN  COLORS  AND  MONOCHROME. 


LEA   BROTHERS   &  CO., 

NEW  YORK   AND    PHILADELPHIA. 

190  4. 


Entered  according  to  Act  of  Congress  in  the  year  1904,  by 

LEA   BROTHERS   &  CO., 

in  the  Office  of  the  Librarian  of  Congress,  at  Washington.     All  rights  reserved. 


ELECTROTYPED  BY  PRINTED  BY 

WESTCOTT  &  THOMSON,  PHILADA.  WILLIAM  J.   DORNAN,  PHILADA. 


0° 

r 

en 


I 


TO 


JAMES  W.  McLANE,  A.M.,  M.D., 

DEAN  OF  THE  FACULTY   AND  EMERITUS  PROFESSOR  OF  OBSTETRICS  AT  THE 

COLLEGE  OF  PHYSICIANS  AND  SURGEONS  (COLUMBIA 

UNIVERSITY),   NEW  YORK. 


AS    AN    EXPRESSION    OF    HIGH    REGARD, 


THIS   WORK   IS   DEDICATIOD   BY 


THE   AUTHOR. 


365365 


PREFACE. 


In  preparing  this  third  edition  the  author  has  endeavored,  as  in  the 
past,  to  present  a  practical,  up-to-date,  and  compact  treatise.  His  aim 
has  been  to  avoid  both  the  tediousness  of  an  encyclopaedia  and  the  dis- 
appointing brevity  of  an  epitome,  and  to  present  a  thorough,  systematic 
description  of  the  cognate  subjects  treated  in  this  volume  in  a  terse 
and  clear  manner.  Care  has  been  exercised  not  to  overburden  the  text 
by  describing  in  detail  as  morbid  entities  symptoms  and  conditions 
which  constitute  well-recognized  abnormal  states.  Over-elaboration  of 
rare  anomalous  conditions,  or  malformations  or  unimportant  diseases 
has  been  avoided,  as  well  as  needless  repetitions  in  the  various  chapters. 

The  endeavor  has  been  made  to  present  only  trustworthy  practical 
information,  and  to  omit  surgical  and  therapeutical  procedures  of  little 
or  doubtful  value. 

The  text  has  been  fully  revised  and  many  new  sections  have  been 
added  throughout  the  work,  with  the  view  of  presenting  the  salient 
phases  of  progress. 

The  various  genito-urinary  affections  have  received  full  consideration, 
and  the  aim  of  the  author  has  been  so  to  simplify  the  subject  that  their 
study  shall  be  easy  and  luminous.  Due  attention  has  been  paid  to  the 
description  of  the  different  operations  upon  the  genito-urinary  system, 
and  the  various  new  operative  procedures  will  also  be  found. 

In  all  matters  relating  to  treatment,  surgical  or  medical,  the  author 
has  aimed  at  presenting  wholesome,  conservative,  and  practical  direc- 
tions ;  and  while  surgery  proper  has  received  full  consideration,  it  has 
been  recognized  that  its  performance  is  but  a  part,  and  not  the  one  aim 
of  therapeusis. 

The  subject  of  gonorrhoea  in  all  its  phases  has  been  exhaustively 
given,  with  full,  practical,  and,  it  is  hoped,  judicious  treatment.  Atten- 
tion has  been  directed  to  the  fallacies  and  dangers  in  some  of  the 
views  nowadays  advanced  in  the  therapeutics  of  this  disease,  and  an 
emphatic  protest  against  them  has  been   made. 

Syphilis  in  all  its  conditions  and  relations  has  been  comprehensively 
considered,  and  much  care  has  been  exercised  in  the  concise  presentation 
of  a  practical,  methodical  course  of  treatment. 

With  the  exception  of  a  few  all  the  illustrations  in  this  volume  have 

5 


6  PREFACE. 

been  made  under  the  personal  supervision  of  the  author  from  his  own 
cases,  and  in  this  edition  twenty-five  new  illustrations  and  twelve  plates 
in  colors  and  monochrome  have  been  added. 

It  is  gratifying  to  mention  the  rapid  exhaustion  of  the  very  large 
second  edition  of  this  work,  and  the  appearance  of  an  Italian  translation 
of  it  issued  by  the  Union  Tipografico  Editrice  of  Turin. 

I  am  indebted  to  Dr.  Ward  A.  Holden  for  the  chapters  on  Syphilis 
of  the  Eye  and  of  the  Ear. 

In  presenting  this  new  edition  I  venture  to  hope  that  it  will  prove  a 
satisfactory  and  trustworthy  guide  for  practitioners  of  medicine  and 
students  who  desire  information  upon  the  subjects  therein  considered. 

ROBERT  W.  TAYLOR. 

142  West  Forty-eighth  Street,  New  York, 
June,  1904. 


CONTENTS 


CHAPTER  I. 

PAGE 

GONORRHOEA  IN   THE   MALE 17 

CHAPTEE  II. 

INVASION  OF  THE  TISSUES   BY  THE  GONOCOCCUS 24 

CHAPTER  III. 
ACUTE  ANTEEIOE  AND  POSTEEIOE  GONORRHOEA,  OR  URETHRITIS   ...     39 

CHAPTER   IV. 

TREATMENT   OF   ACUTE   ANTERIOR   AND    POSTERIOR    GONORRHOEA,    OR 

URETHRITIS       56 

CHAPTER  V. 
CHRONIC  ANTERIOR  AND  POSTERIOR  GONORRHOEA,   OR  URETHRITIS  .    .     73 

CHAPTER  VI. 
TREATMENT  OF  CHRONIC  ANTEEIOR   AND  POSTERIOR  GONORRHOEA  .    .     83 

CHAPTER  VII. 
GONORRHOEA  OF  THE   RECTUM  AND  MOUTH     .' 95 

CHAPTER  VIII. 
COMPLICATIONS  OF  GONORRHOEA 98 

CHAPTER  IX. 
GONORRHOEA  IN   THE   FEMALE 149 

CHAPTER  X. 
STRICTURE   OF  THE  URETHRA     , 172 

CHAPTER  XI. 

AFFECTIONS   OF  THE   PENIS 009 

7 


8  CONTEXTS. 

CHAPTER  XII. 

PAGE 

AFFECTIONS  OF  THE  SCEOTUM 284 

CHAPTER  XIII. 
AFFECTIONS   OF  THE  URETHRA 286 

CHAPTER  XIV. 
AFFECTIONS   OF  THE   PROSTATE 288 

CHAPTER  XV. 
AFFECTIONS  OF  THE   TESTIS  AND  ITS  APPENDAGES  AND  ENVELOPES  .   328 

CHAPTER  XVI. 
AFFECTIONS   OF  THE   SPERMATIC   CORD 362 

CHAPTER  XVII. 
AFFECTIONS  OF  THE   SEMINAL  VESICLES 3G8 

CHAPTER  XVIII. 
AFFECTIONS   OF  THE   BLADDER  . 370 

CHAPTER  XIX. 

AFFECTIONS   OF  THE  URETERS 396 

CHAPTER    XX. 
AFFECTIONS  OF  THE  KIDNEY .407 

CHAPTER  XXI. 

MISCELLANEOUS  AFFECTIONS   OF  THE  GENITO-UEINAEY  SYSTEM     ...    428 

CHAPTER  XXII. 

PREPARATION    OF   THE    PATIENT    FOE    OPERATIONS    AND    OF    INSTRU- 
MENTS     433 

CHAPTER  XXIII. 
THE  CHANCROID,  OR   SOFT  CHANCRE 435- 

CHAPTER   XXIV. 
SYPHILIS      463 

CHAPTER  XXV. 

COMPLICATIONS  AND  GENERAL  CONSIDERATION   OF  SYPHILIS 474 


CONTENTS.  9 

CHAPTER   XXVI. 

PAGE 

PATHOLOGY    OF    SYPHILITIC     INFECTION    AND    OF     THE     SYPHILITIC 

PKOCESSES ! 488 

CHAPTER   XXVII. 
VEHICLES   OF  INFECTION   IN   SYPHILIS 494 

CHAPTER   XXVIII. 
THE   CHANCRE,  OR   THE   INITIAL   LESION   OF  SYPHILIS 499 

CHAPTER   XXIX. 
PRIMARY  SYPHILIS .    ...   522 

CHAPTER   XXX. 

SECONDARY   SYPHILIS         .    . 527 

CHAPTER   XXXI. 
SECONDARY  ERUPTIONS,  OR   SYPHILIDES 536 

CHAPTER   XXXII. 
SYPHILITIC   AFFECTIONS  OF   THE   VARIOUS   MUCOUS   MEMBRANES  ...   566 

CHAPTER   XXXIII. 
SYPHILITIC  AFFECTIONS  OF  THE  HAIR 574 

CHAPTER   XXXIV. 
SYPHILITIC   AFFECTIONS   OF   THE   NAILS 578 

CHAPTER   XXXV. 

SYPHILITIC  AFFECTIONS   OF   THE   EYE 584 

CHAPTER   XXXVI. 
SYPHILITIC  AFFECTIONS   OF  THE  EAR 595 

CHAPTER   XXXVII. 
TERTIARY   SYPHILIS 598 

CHAPTER   XXXVIII. 

THE  TERTIARY   SYPHILIDES      604 


10  CONTENTS. 

CHAPTER   XXXIX. 

PAGE 

SYPHILITIC    AFFECTIONS   OF    THE    TONGUE,   THE    SOFT    PALATE,    THE 

PHARYNX,    THE   LAEYNX,   AND   THE   CESOPHAGUS    .    .  ' 618 


CHAPTER   XL. 

SYPHILITIC    AFFECTIONS    OF    THE    TRACHEA,    BRONCHI,    LUNGS,    AND 

HEART 626 


CHAPTER   XLI. 
TERTIARY   AFFECTIONS  OF   THE   VISCERA 630 

CHAPTER   XLII. 

SYPHILITIC    AFFECTIONS     OF    THE     MUSCLES,     TENDINOUS    SHEATHS, 

APONEUROSES,   AND   BURStE 637 

CHAPTER   XLIII. 
SYPHILITIC  AFFECTIONS  OF  THE  BONES,  JOINTS,  FINGERS,  AND  TOES  .   641 

CHAPTER   XLIV. 

SYPHILITIC     AFFECTIONS    OF    THE    PENIS,    OS    UTERI,    UTERUS,     AND 

VAGINA 652 

CHAPTER   XLV. 

SYPHILITIC  AFFECTIONS   OF   THE  EPIDIDYMIS   AND   TESTIS 654 

CHAPTER   XLVI. 
SYPHILITIC   AFFECTIONS   OF   BLOODVESSELS 658 

CHAPTER   XLVII. 
SYPHILITIC  AFFECTIONS   OF  THE   NERVOUS  SYSTEM 660 

CHAPTER   XLVIII. 

THE  GENERAL   METHODICAL   TREATMENT   OF   SYPHILIS     ........    670 

CHAPTER   XLIX. 

HEREDITARY  SYPHILIS ~00 


GENITO-URINARY  AND  VENEREAL  DISEASES, 
AND  SYPHILIS. 


CHAPTER   I. 

GONORRHOEA  IN  THE  MALE. 

Gonorrhcea,  the  most  frequent  of  all  venereal  diseases,  and  the  one 
essentially  of  sexual  origin,  is  a  virulent  process,  attended  by  much  sup- 
puration, which  attacks  chiefly  the  mucous  membrane  of  the  urethra, 
male  and  female,  and  the  parts  in  immediate  and  more  remote  anatom- 
ical relation.  The  mucous  membrane  of  the  eye  is  also  particularly 
susceptible  to  its  action.  There  is  no  doubt  that  the  rectal  and  anal 
mucous  membrane  may  be  attacked  by  this  process,  but  there  is  much 
doubt  about  the  existence  of  gonorrhoea  of  the  mouth  and  nose.  In 
this  work  the  terms  gonorrhoea  and  urethritis  will  be  used  interchange- 
ably. 

Gonorrhoea  is  mostly  found  in  young  men ;  but  instances  of  children, 
and  even  infants,  being  thus  affected  are  far  from  uncommon.  Toward 
puberty  it  is  very  often  found  in  the  male  ;  while  between  the  twentieth 
and  thirtieth  years  its  frequency  of  occurrence  is  greatest.  From  the 
thirtieth  year  onward  its  occurrence  grows  progressively  less  frequent, 
but  it  is  seen  in  a  goodly  number  of  cases  of  middle-aged,  and  even  of 
old,  men. 

Gonorrhoea  occurs  much  more  frequently  in  the  male  than  in  the 
female.  The  first  attack  is  usually  more  acute  and  severe  than  are 
subsequent  ones,  which  are  very  often  subacute  in  form  and  chronic  in 
course.  When  many  years  have  elapsed  between  two  infections,  the 
second  may  be  equally  as  severe  as  the  first.  In  very  many  cases  of 
men  who  have  had  in  the  past  an  attack  of  gonorrhoea  acute  urethral 
suppuration  may  be  solely  due  to  sexual  and  alcoholic  excesses,  which 
have  changed  a  chronic  and  dormant  localized  inflammation  of  the  ure- 
thra into  a  more  or  less  acute  condition.  This  affection  is  called  by 
some  bastard  gonorrhoea,  and  by  others  simple  urethritis. 

Gonorrhoea  is  one  of  the  most  persistent  diseases  which  attack  mucous 
membranes.  It  invades  the  tissues  deeply,  and  as  a  consequence  it  is 
very  often  difficult  to  cure.  After  a  more  or  less  prolonged  chronic 
2  17 


18  GONOBRHCEA   IN  THE  MALE. 

stage  it  often  settles  down  into  a  latent  and  dormant  condition  in  a 
localized  form,  and  may  thus  cause  no  symptoms  for  years.  Then, 
again,  this  condition  of  latency  may  be  frequently  varied  by  acute 
attacks  of  the  disorder. 

In  many  cases  it  passes  away  and  leaves  no  bad  effects.  In  others  it 
leads  to  the  development  in  the  male  of  such  painful  complications  as 
swelled  testicle  and  abscess  in  connection  with  the  urethra.  In  the 
female  it  may  lead  to  cystitis,  inflammation  of  the  os  uteri,  the  tubes, 
the  ovaries,  and  even  to  peritonitis.  Its  long  duration  in  the  male  ure- 
thra frequently  leads  to  stricture,  with  its  distressing  and  often  fatal 
results  from  bladder,  prostatic,  and  kidney  complications.  By  the  action 
of  the  toxins  which  the.  gonorrhoeal  process  gives  forth,  and  also  from 
the  absorption  of  its  virulent  microbes  from  the  urethra  into  the  circu- 
lation, violent  and  painful  inflammations  of  joint-structures,  joints, 
tendinous  sheaths,  bursae,  fasciae,  and  fibrous  tissues  are  produced.  In 
many  of  these  inflammations  gonorrhoea  seems  to  produce  a  true  septi- 
caemia through  the  action  of  its  own  virulent  microbe.  In  many  cases 
it  is  very  probable  that  the  morbid  action  of  the  gonococcus  prepares 
the  tissue  for  the  invasion  of  pyogenic  microbes.  By  these  combined 
or  mixed  forms  of  infection  the  whole  organism  may  be  involved,  and 
severe  illness,  structural  impairment  of  parts,  invalidism,  and  even 
death,  may  be  produced.  By  reason  of  this  action  of  the  gonococcus 
alone  or  aided  by  that  of  other  pyogenic  microbes  the  eyes,  the  heart 
and  its  membranes,  the  coverings  of  the  spinal  cord  (and,  it  is  also 
claimed,  those  of  the  brain)  may  be  attacked,  aud  serious,  even  fatal 
results  may  follow. 

When  we  consider  the  vast  range  of  pathological  conditions  which 
gonorrhoea  may  cause  or  lead  to,  we  are  certainly  warranted  in  assert- 
ing that  it  is,  taken  as  a  whole,  one  of  the  most  formidable  and  far- 
reaching  infections  by  which  the  human  race  is  attacked. 

In  the  vast  majority  of  cases  of  gonorrhoea  the  gonococcus  is  the 
infecting  agent  and  in  a  minority  a  number  of  pyogenic  microbes, 
notably  the  staphylococci  and  streptococci,  are  the  causative  factors. 

Predisposing  Conditions  and  Causes. — The  size  and  conditions  of 
the  penis  are  frequently  factors  in  the  contracting  of  gonorrhoea.  Thus 
a  very  long  organ  is  frequently  infected  by  pus  from  the  uterine  neck 
or  fornix  vaginae,  while  a  shorter  one  may  escape.  A  very  large  and 
thick  organ  may  give  rise  to  friction  and  irritation,  and  in  that  way 
become  infected.  Patients  with  naturally  large  meatuses,  and  particu- 
larly those  in  whom  unnecessarily  large  meatotomy  has  been  practised, 
are  also  very  susceptible.  A  meatus  which  opens  on  the  under  surface 
of  the  glans  resembling  hypospadias,  and  the  condition  of  hypospadias 
itself,  predispose  its  bearer  to  gonorrhoeal  infection.     Then,  again,  cases 


THE  GONOCOCCUS.  19 

are  seen  in  which  this  form  of  the  opening  exists,  and  with  it  shortness 
and  tightness  of  the  frsenum,  and  perhaps  of  the  prepuce.  In  such 
cases  there  are  much  redness  of  the  fossa  navicularis  and  a  marked  ten- 
dency to  acquire  gonorrhoea.  In  these  cases,  and  in  those  of  hypospadias 
where  the  meatus  is  thus  placed  low  in  the  glans,  it  is  probable  that  the 
secretions  of  the  vagina,  which  gravitate  to  its  posterior  wall,  are  sucked 
in  by  capillary  attraction,  and  find  easy  entry  into  the  fossa  navicularis 
and  urethra,  and  there  produce  infection. 

In  fact,  any  structural  condition  that  causes  hyperemia  of  the  dis- 
tal part  of  the  penis  may  render  its  bearer  liable  to  contract  gonorrhoea. 

Long-continued  copulation,  particularly  in  persons  under  the  influ- 
ence of  alcoholics,  is  a  potent  factor  of  infection.  In  such  cases  ejacu- 
lation is  much  delayed,  the  penis  and  vagina  are  much  irritated,  and 
gonorrhoea  very  frequently  follows.  Indeed,  venereal  excesses  are 
common  and  prolific  causes  of  gonorrhoea.  Persons  who  have  recently 
recovered  from  an  attack  of  gonorrhoea  are  especially  predisposed  to 
subsequent  infections. 

There  can  be  no  question  that  in  some  cases  of  early  syphilis  the 
distal  parts  of  the  urethra  are  rendered  more  prone  to  the  invasion  of 
gonococci  and  other  microbes.  This  tendency  may  be  brought  into 
action  by  abnormal  conditions  of  these  parts,  and  may  exist  in  cases 
where  no  abnormality  is  present.  An  active  syphilitic  diathesis  can 
undoubtedly  be  at  the  root  of  the  persistence  of  a  gonorrhoea,  and  may 
also  be  a  factor  in  the  induction  of  relapses.  It  must  be  borne  in  mind 
that  the  disease  then  is  not  syphilitic  in  nature.  It  is  an  infective 
urethritis,  due  to  micro-organisms,  occurring  in  a  syphilitic  in  whom 
the  diathesis  is  still  active  and  whose  tissues  are  more  vulnerable  to 
irritation  and  microbic  invasion  than  those  of  a  previously  healthy 
person. 

THE    GONOCOCCUS. 

The  gonococcus  is  clearly  revealed  to  the  eye  by  means  of  staining- 
processes  and  by  the  microscope  with  a  high  power  and  oil-immersion, 
using  at  least  a  y^-inch  lens.  It  is  a  relatively  large  micrococcus, 
nearly  always  appearing  as  a  diplococcus.  It  measures  0.8  to  1.6 
micromillimetres  in  length  and  0.6  to  0.8  micro- 
millimetres  in  breadth.     The  gonococci  are  usually  Fig.  1. 

found  in  pairs,  each  half  of  the  diplococcus  being:        f$  ®  @&  @b  €8> 

f  i-A  u  a  +i      +         +u  ui  ^  W  ^  W  O 

oi    kidney  shape,  and  the   two    thus    resemble    a 

no       i  171  i  11         /-w  ,i  •  Morphology  of  the  gono- 

cotiee-bean  or  a  J*  rencn  roll.     Occurring  thus  in        coccus  (after  Bumm). 
pairs,    they    lie    close    together,     their    flattened 

surfaces  being  in  close  coaptation  and  their  outer  margins  convex. 
Between  each  coccus  is  a  very  narrow  split  which  shows  as  a  bright 


20  OONORBHCEA   IN  THE  MALE. 

line.  In  these  particulars  the  gonococcus  resembles  other  diplococci. 
In  its  multiplication  this  diplococcus  divides  by  a  transverse  cleavage 
or  at  right  angles  to  the  median  fissure.  By  this  means  of  fission  each 
pair  of  the  diplococcus  is  converted  into  four  diplococci,  which  are 
grouped  in  fours.  The  mode  of  division  is  schematically  pictured 
in  Fig.  1.  Beginning  at  the  left  hand  of  the  figure,  the  line  of 
cleavage  is  shown  to  be  more  and  more  distinct  until  the  full  develop- 
ment is  reached,  as  pictured  in  the  right-hand  figure.  In  this  way 
these  micro-organisms  increase  and  multiply.  Other  diplococci,  how- 
ever, develop  in  a  similar  manner.  From  this  method  of  transverse 
fission  and  growth  originates  the  peculiar  grouping  of  the  gonococcus 
into  twos  and  fours  and  their  multiple  derivatives. 

In  the  acute  stage  of  gonorrhoea  these  diplococci  are  found  in  greater 
or  less  number  encapsulated  in  masses  within  the  pus-cell.  When 
numerous  and  thus  seated  they  have  been  said  to  present  the  appear- 
ance of  a  swarm  of  bees.  Under  rather  low  powers  they  look  like  little 
particles  of  gunpowder.  They  may  be  so  numerous  within  a  pus-cell 
as  to  rupture  its  wall.  Then  we  find  the  cocci  lying  free  in  the  serum, 
scattered  in  a  disordered  manner  between  the  pus-cells,  but  even  then 
presenting  the  four  and  multiple-of-four  arrangement.  Early  in  the 
infection  gonococci  are  seen  seated  upon  epithelial  cells. 

Under  microscopical  examination  gonococci  are  readily  found  and 
recognized  in  the  pus  of  acute  gonorrhoea.  Then  the  clinical  features 
of  the  infection  and  the  microscopical  picture  of  the  discharge  and  its 
pus,  epithelium,  if  present,  and  diplococci,  taken  together,  are  so  strik- 
ing and  unvarying  that  a  mistake  can  scarcely  occur.  But  in  later 
stages  of  true  gonorrhoea,  and  in  many  more  or  less  subacute  cases  of 
urethral  suppuration,  it  is  very  often  most  difficult,  and  sometimes 
impossible,  to  say  whether  the  microbe  is  the  gonococcus  or  some  other 
form  of  diplococcus.  In  all  cases  the  crucial  test  rests  in  cultivations 
and  inoculations.  ' 

While,  however,  there  is  no  single  individual  sign  or  mode  of  dis- 
tinction of  the  gonococcus,  there  are  a  number  of  signs  which,  when 
taken  together,  offer  strong  presumptive  evidence  that  the  microbe  in 
question  is  the  one  just  named.     These  are — 

1.  The  shape,  which  is,  as  we  have  seen,  roundly  oval,  with  its 
median  fissure  and  its  roll-like  or  coffee-bean  appearance,  and  its  length- 
wise fissure. 

2.  The  size  :  they  are  large  diplococci,  and  in  their  development  are 
variable  and  resemble  other  diplococci. 

3.  The  grouping,  as  a  result  of  their  mode  of  division,  is  in  single 
pairs,  in  fours,  eights,  sixteens,  etc.     They  never  occur  in  chains. 

4.  Their  intracellular  position  :    the  gonococci  are  found  in  heaps 


THE  GONOCOCCUS.  21 

within  the  protoplasm  of  the  pus-cells,  and  also  scattered  between  the 
cells  in  varying  numbers.  Other  diplococci,  however,  are  also  found 
within  the  pus-cell. 

5.  Their  staining  properties :  gonococci  are  readily  stained  by 
aniline  colors,  and  they  readily  lose  their  staining  by  Gram-Roux's 
method.  This  quality  is  very  characteristic  of  the  gonococcus,  but  it  is 
also  possessed  by  certain  other  diplococci,  by  streptococci,  and  by 
staphylococci. 

Methods  of  Staining'. — For  general  purposes  a  solution  of  methyl 
blue  is  all  that  is  needed  for  staining  gonococci,  but  fuchsine,  methyl 
violet,  gentian  violet,  and  victoria  blue  may  be  used.  The  technic  is 
as  follows  :  Spread  by  means  of  a  platinum-wire  loop  some  of  the  pus, 
threads,  or  secretion  on  a  cover-glass  in  a  very  thin  film,  or  place  a  drop 
of  the  secretion  in  the  centre  of  a  cover-glass,  and  then  place  another 
cover-glass  over  this.  Then  separate  the  two  by  sliding  them  over  each 
other,  not  by  pulling  them  apart.  In  this  way  two  evenly-spread  speci- 
mens are  obtained.  It  is  always  necessary  to  wash  thoroughly  the  glans 
penis  and  the  meatus  before  taking  the  secretion,  since  many  microbes 
are  seated  on  these  parts.  In  taking  secretions  from  the  female  genitals 
scrupulous  care  should  be  exercised,  so  that  no  extraneous  or  accidental 
micro-organisms  are  gathered  up.  In  dispensary  work  the  secretion 
from  the  male  urethra  may  be  allowed  to  drop  upon  a  glass  slide,  and  it 
is  then  to  be  spread  out  over  its  surface  by  drawing  the  edge  of  a  sim- 
ilar slide  over  it.  The  specimen  may  be  allowed  to  dry  in  the  air  or  it 
may  be  passed  two  or  three  times  (the  right  side  up)  through  an  alcohol 
or  gas  flame.  The  dried  secretion  is  then  lightly  smeared  with  the 
staining  fluid  by  means  of  a  glass  rod. 

The  simplest  and  most  expeditious  method  of  staining  these  speci- 
mens is  to  put  a  drop  of  a  dilute  watery  solution  of  methyl  blue  upon 
the  cover-glass,  allow  it  to  remain  two  or  three  minutes,  wash  off  with 
water,  and  then  examine  in  water.  This  may  be  allowed  to  dry, 
and  then  it  may  be  mounted  in  Canada  balsam.  By  this  method,  how- 
ever, the  gonococci  are  not  shown  so  clearly  as  by  others  to  be  men- 
tioned. 

One  of  the  most  satisfactory  and  rapid  methods  of  examination  is 
that  recommended  by  Schiitz.  This  is  founded  on  the  resistance  of  the 
gonococcus  to  acetic  acid  after  being  stained  with  methyl  blue.  After 
the  cover-glass  is  covered  with  a  thin  film  of  the  suspected  material  it 
is  passed  three  times  through  the  flame.  It  is  then  brought  in  contact 
with  a  saturated  solution  of  methyl  blue  in  5  per  cent,  carbolic-acid 
water  for  five  or  ten  minutes.  It  is  then  washed  with  water  and  placed, 
for  a  time  long  enough  to  count  one,  two,  three  slowly,  in  a  solution  of 
five  drops  of  acetic  acid  in  twenty  cubic  centimeters  of  distilled  water, 


22  GONORRHOEA  IN  THE  MALE. 

and  immediately  washed  again  in  pure  water.  Everything  is  then 
decolorized  except  the  gonococci,  which  remain  distinctly  blue.  The 
specimen  may  be  then  examined  and  preserved,  or  at  this  stage  it  may 
be  double  stained  with  a  very  dilute  aqueous  solution  of  safranine.  This 
second  staining  should  be  very  slight,  the  cover-glass  being  washed  at 
once  in  pure  water.  By  this  process  the  gonococci  will  be  found  of  a 
deep-blue  color,  the  epithelial  cells  of  the  same  color,  while  the  pus-cells 
and  their  nuclei  will  be  salmon-colored. 

Technic  of  Gram's  Method  for  Staining  Gonococci. — The  most 
reliable  means  of  recognizing  the  gonococcu*  is  that  known  as  the  Grarn- 
Eoux  method.  The  procedure  is  as  follows:  1.  Make  a  smear  of  the 
suspected  discharge  on  a  cover-glass  or  slide.  2.  Pass  same  three  times 
through  the  flame  of  an  alcohol  lamp  or  Bunsen  burner.  3.  Stain  for 
two  to  four  minutes  with  anilin  gentian-violet  solution,  made  as  follows : 
anilin  oil,  1  part;  distilled  water,  20  parts.  Shake  well.  Filter  through 
moistened  filter-paper.  To  nitrate  add  saturated  alcoholic  solution  of 
gentian-violet  in  the  proportion  of  1  part  to  10  of  filtrate.  This  should 
be  made  fresh  every  day.  4.  Transfer  specimen  directly  to  solution  of: 
iodine,  1  part;  potassium  iodide,  2  parts;  water,  300  parts.  Allow  it  to 
remain  from  one'to  three  minutes.  5.  Transfer  to  absolute  alcohol,  which 
should  be  changed  two  or  three  times  until  decolorization  of  specimen  is 
completed.  6.  Transfer  to  solution  of  Bismarck  brown  (saturated  alco- 
holic solution  B.B.,  1  part ;  water,  10  to  20  parts).  Stain  for  half  a 
minute.  7.  Dry  and  mount  in  balsam  ;  or  if  it  is  not  desired  to  pre- 
serve specimen,  it  may  be  examined  directly  by  oil  immersion  lens  with 
the  aid  of  oil  of  cedar.  By  this  method  the  pus-cells  are  stained  a  light 
brown,  and  the  gonococci  are  decolorized  and  are  shown  in  marked  con- 
trast imbedded  in  the  cells.  This  method  is  considered  the  most  reliable 
for  the  diagnosis  of  gonococci  in  a  specimen  of  urethral  discharge.  There 
are  a  number  of  other  cocci,  however,  which  are  decolorized  by  the  use 
of  Gram's  method,  so  that  the  situation  and  morphology  of  the  cocci 
should  be  taken  into  account  in  making  the  diagnosis. 

Roux  says  that  he  learned  by  experiments  that  Gram's  liquid  does 
not  sufficiently  and  firmly  fix  the  basic  aniline  colors  in  gonococci,  but 
that  as  soon  as  the  specimen  is  treated  with  absolute  alcohol  these  cocci 
and  the  anatomical  elements  become  very  difficult  to  recognize  with  the 
microscope.  This  negative  fact  therefore  constitutes  an  element  of  diag- 
nosis, since  other  micro-organisms  do  not  thus  become  decolorized.  He 
claims,  therefore,  that  when  the  presence  of  gonococci  is  shown  by  ani- 
line dyes,  and  upon  the  addition  of  Gram's  liquid  and  alcohol  they  dis- 
appear, it  is  certain  that  Xeisser's  coccus  is  present.  On  the  other  hand, 
if  the  micro-organisms  remain  stained,  they  are  in  all  probability  not 
gonococci. 


THE  GONOCOCCUS.  23 

No  trouble  will  be  experienced  in  studying  the  secretion  of  acute 
gonorrhoea  even  when  some  weeks  old.  But  the  doubt  arises  in  sub- 
acute and  chronic  cases,  just  the  ones  in  which  we  are  anxious  to  deter- 
mine whether  the  long-drawn-out  inflammation  is  really  kept  up  by  the 
gonococcus,  and  whether  this  micro-organism  has,  as  it  is  claimed  it  has, 
an  indefinite  life  as  a  morbific  agent  in  the  male  urethra. 

A  New  Stain  for  Gonococci  in  Chronic  Gonorrhoea. — It  is  well 
known  that  the  secretion  of  chronic  gonorrhoea  is  very  difficult  to  stain, 
and  that  the  basic  aniline  dyes  are  not  convenient  for  this  purpose,  as  they 
fade  quickly  and  stain  gonococci  and  nuclei  alike,  v.  Wahl  therefore 
suggests  a  mixture  of  auramine  and  thionin,  consisting  of  15  c.c.  of  a 
saturated  alcoholic  solution  of  "  auramine  II."  (1:10)  and  from  8  to 
10  c.c.  of  a  saturated  alcoholic  solution  of  thionin  (1  :  20),  to  which  30 
c.c.  of  distilled  water  are  added  after  shaking.  If  a  bright  staining  of 
the  cellular  elements  is  aimed  at,  it  is  advisable  to  add  a  little  watery 
solution  of  methyl-green  (1  :  50)  and  a  corresponding  amount  of  thionin. 
The  nuclei  are  then  stained  bluish-green  and  the  gonococci  deep  violet. 
The  mixture  without  these  additions  stains  (in  from  ten  to  fifteen  seconds) 
the  cellular  elements  a  light  green  and  the  gonococci  a  dark  violet. 

Fig.  2. 
i 

,»  *   *    8  f 

*        % 
I 


0  •    «»«»  *•  i 


Showing  on  the  left  half  some  groups  of  gonococci  obtained  by  culture,  and  on  the  right  half  some 
groups  of  a  so-called  pseudogonococcus  cultivated  from  a  specimen  derived  from  a  normal 
urethra  virgin  to  gonorrhoea. 

This  micro-organism  outside  of  the  human  body  has  little  vitality. 
Its  culture  media  are  blood-serum,  and  blood-serum  and  agar-agar,  and 
urine  and  urea,  in  acid  solution. 

It  is  well  to  emphasize  the  following  facts  :  In  the  normal  urethra 
are  found  innocuous  and  virulent  microbes  of  whose  history  and  patho- 
genic power  we  as  yet  know  little.  Whether  these  organisms  play  any 
part  in  urethral  inflammation  we  do  not  now  know.  One  of  them 
termed  a  pseudogonococcus  so  much  resembles  the  gonococcus  that  it  is 
a  source  of  error  in  5  per  cent,  of  cases  of  the  recognition  of  the  latter 
(see  Fig.  2). 


CHAPTER    II. 

INVASION  OF   THE   TISSUES  BY  THE  GONOCOCCUS. 

The  process  of  the  invasion  of  the  tissues  by  the  gonococeus  may 
now  be  considered.  Owing  to  the  great  difficulty,  and  at  times  impossi- 
bility, of  obtaining  a  urethra  the  seat  of  active  gonococci  invasion,  Bumrn 
studied  the  subject  upon  the  conjunctiva  of  infants  inoculated  with  gono- 
cocci-containing  pus.  As  the  mucous  membrane  of  the  eye  resembles 
that  of  the  urethra,  and  as  the  two  membranes  react  similarly  to  gonor- 
rheal infection,  it  is  fair  to  assume  that  the  morbid  processes  and 
appearances  are  similar  in  each  instance.  It  is  this  want  of  pathological 
material  on  my  own  part  which  forces  me  here  to  make  use  of  Bumrn's 
observations  and  results. 

Having  gained  a  foothold  on  the  superficial  epithelial  layers,  and  there 
having  greatly  increased  in  numbers,  the  gonococci  penetrate  between  the 
epithelial  cells,  which  have  become  swollen  and  succulent,  into  the  soft 
protoplasm  substance.  It  is  interesting  to  note  that  in  the  infective  proc- 
ess the  cocci  themselves  are  the  active  agents  in  attack  and  penetration, 
and  that  they  are  not  enclosed  in  pus-cells.  Indeed,  active  participation 
of  the  pus-cell  is  not  observed.  The  spreading  of  the  micro-organisms 
onward  is  thought  by  Bumm  to  be  due  to  their  growing  more  actively  on 
one  side — a  condition  caused  by  the  difference  in  soil  and  probably  by  an 
increased  supply  of  oxygen.  In  all  cases  the  road  traversed  by  the  gono- 
cocci is  through  the  cement-substance  between  the  cells.  Sometimes  they 
penetrate  in  single  rows;  then  again  they  advance  in  a  larger  body; 
and  when  the  tissues  will  admit,  they  form  a  roundish  colony,  and 
from  that  nidus  make  further  incursions  into  the  tissues.  "When  they 
have  got  well  down  toward  the  subepithelial  connective-tissue  layer, 
reaction  on  the  part  of  the  tissues  occurs.  Then  great  numbers  of  white 
blond-cells  escape  from  the  dilated  capillaries,  together  with  much  serum. 
This  stream  of  pus,  pouring  out,  breaks  through  the  epithelium  or  even 
carries  it  away  in  small  or  large  plates.  The  removal  of  the  epithelium 
then  permits  further  invasion  of  the  gonococci  even  to  the  papillary 
layer,  but  there  it  stops.  Pus-cells  with  the  gonococci  may  now  be  seen, 
but  free  gonococci  are  much  more  numerous.  Coincidently  with  this 
cocci  invasion  and  multiplication  the  inflammatory  process  increases  in 
intensity,  and  a  dense  round-cell  infiltration  is  formed  beneath  the  sur- 
face of  the  mucous  membrane.     This  is  the  transition  to  the  purulent 

24 


PLATE   I. 


4m 


■f-'-r-   - 


INVASION  OF  THE  TISSUES  BY  THE  GONOCOCCUS. 


INVASION  OF  THE  TISSUES  BY  THE  GONOCOCCUS.  25 

stage  of  gonorrhoea.  In  some  cases,  as  early  as  the  twelfth  day  regenera- 
tion of  the  epithelium  begins  and  rapidly  progresses,  and  then  the  fur- 
ther invasion  of  the  micro-organism  may  be  stopped.  During  this 
reparative  process  the  pus-cells  escape  unhindered,  and  rows  and  clusters 
of  gonococci  may  be  harbored  between  the  cells  of  the  uppermost  layer 
of  the  epithelial  strata.  Under  some  circumstances  there  may  then  be  a 
new  invasion  by  the  gonococci.  An  outpouring  of  pus  destroys  more  or 
less  of  the  epithelial  layer,  and  this  opens  the  way  for  a  second  invasion. 
This  condition  is  what  occurs  in  relapses  of  acute  and  moderately  acute 
gonorrhoea.  The  cocci  may  develop  between  the  superficial  connective 
tissue  and  the  tunica  propria,  but  they  do  not  luxuriate.  It  seems  proba- 
ble that  they  do  not  find  in  the  deep  parts  of  the  mucous  membrane  the 
conditions  necessary  for  development,  or  that  they  are  unable  to  withstand 
the  influence  exercised  by  the  tissue-elements.  They  are  most  at  home 
in  the  superficial  layers  of  the  connective  tissue  and  between  the  epithe- 
lial cells. 

In  this  infective  process,  therefore,  we  see  a  violent  invasion  of  a 
mucous  membrane  by  large  masses  of  gonococci  which  penetrate  between 
the  cells.  There  is  always  to  be  observed  a  connection  between  the 
multiplication  and  activity  of  the  micro-organism  and  the  intensity  of  the 
inflammatory  process.  The  reaction  on  the  part  of  the  tissues  corre- 
sponds to  the  intensity  of  the  irritation  excited  in  the  soft  and  sensitive 
epithelium.  So  long  as  there  is  secretion  present  on  a  mucous  mem- 
brane, the  gonococci  may  remain  in  it  and  multiply,  for  it  offers  a  favor- 
able culture-soil.  The  great  mass  of  gonococci  in  the  uppermost  strata 
of  tissues  perish  there  from  simple  dissolution.  Final  healing  is  caused 
not  so  much  through  the  elimination  of  the  micro-organisms  as  by  the 
development  of  a  protective  covering  of  squamous  epithelium  in  several 
strata  which  closes  all  gaps,  cracks,  and  inlets  to  further  invasion. 
The  infective  process  is  therefore  brought  to  an  end  by  the  energetic 
development  of  epithelium,  which  forms  a  barrier  which  the  gonococci 
cannot  break  through.     (Plate  I.) 

It  is  very  probable  that  when  gonorrhoea  is  caused  by  the  staphylo- 
coccus and  the  streptococcus  the  pathological  processes  and  changes  are 
similar  to  those  produced  by  the  gonococcus.  Clinical  and  microscopical 
study  shows  that  different  individuals  are    affected    in  different  ways. 


Explanation  of  Plate  I. 

a,  epithelial  layer  covered  with  pus-cells  and  gonococci.  b,  penetration  of  tissues  by 
colonies  of  gonococci.  c,  diffuse  superficial  development  of  gonococci.  d,  superficial 
colonies  invading  epithelial  layers,  e,  further  penetration  of  the  colonies  into  the  tissues. 
/',  still  further  penetration  of  the  colonies,  g,  penetration  into  superficial  portions  of  a 
papilla.  h,  penetration  of  gonococci  into  the  intrapapillary  layer,  i,  recurrent  invasion 
with  development  of  squamous  epithelium. 


26  INVASION  OF  THE  TISSUES  BY  THE  GONOCOCCUS. 

In  some  the  attack,  as  shown  by  the  discharge,  comes  on  briskly  and 
promptly,  while  in  others  the  morbid  process  develops  slowly  and 
insidiously,  and  often  with  much  halting.  In  the  very  earliest  period 
of  gonorrhoea  much  can  be  learned  as  to  the  mode  of  invasion  of  the 
disease,  and  as  to  the  pathological  conditions  in  a  given  case,  by  the 
microscopic  examination  of  the  secretion.  This  scientific  examination 
should  be  made  in  every  case,  since  from  its  results  indications  of  a 
practical  nature  may  be  derived.  Not  only  in  the  very  earliest  stage 
does  the  microscope  give  much  aid  and  broad  enlightenment  in  pathol- 
ogy and  treatment,  but  throughout  the  whole  course  of  gonorrhoea  its 
teachings  are  invaluable. 

As  will  be  shown  farther  on,  the  number  of  gonococci  in  the  serous 
discharge  of  the  first  day  or  two  shows  very  great  differences  in  indi- 
vidual cases.  In  some  periods,  the  earlier  as  a  rule,  there  are  enormous 
numbers  of  gonococci  in  the  discharge,  while  during  the  latter  stages  of 
the  attack  there  are  frequently  so  few  of  them  that  but  one  or  two  pus- 
cells  can  be  found  in  the  entire  field  containing  gonococci.  So  a  drop 
of  discharge  at  one  stage  of  the  attack  may  contain,  estimating  it 
roughly,  but  two  or  three  or  several .  hundred  gonococci,  while  at 
another  time  the  drop  holds  enormous  quantities  of  the  cocci — a  million 
or  more. 

Thus  when  gonorrhoea  is  contracted,  as  a  result  either  of  the  dura- 
tion of  the  exposure  to  the  infecting  pus  or  according  to  the  stage  of 
development  of  the  discharge  in  the  donor,  the  number  of  gonococci 
received  may  vary  within  very  wide  limits.  This  numerical  variability, 
then,  in  the  gonococci  seems  in  a  measure  to  determine  the  period  of 
incubation  and  the  character  of  the  onset  of  the  discharge.  The 
vulnerability  of  the  tissues  and  the  conditions  favorable  to  inflamma- 
tion also  have  much  to  do  with  the  promptitude  of  the  onset  of  the 
inflammation. 

In  some  cases,  where  a  very  few  gonococci  englobed  in  the  pus-cells 
are  received,  the  discharge  does  not  become  visible  for  some  days, 
although  during  this  time  there  is  an  exudation,  but  it  is  so  scanty  and 
colorless  that  it  escapes  attention.  In  such  a  case  as  this  it  would  seem 
that  so  few  gonococci  entered  the  urethra  that  some  days  are  requisite 
for  them  to  proliferate  extensively  enough  to  produce  a  widespread 
chemotaxis  or  attraction  of  the  leucocytes  from  the  blood-vessels  of  the 
urethral  mucosa,  or  that  the  tissues  were  not  particularly  vulnerable. 
After  the  gonococci  have  proliferated  and  become  more  extensively  dis- 
tributed over  the  urethra,  a  widely-spread  and  severe  exudative  inflam- 
mation of  the  canal  takes  place  more  or  less  suddenly.  An  attack  of 
gonorrhoea  would  be  liable  to  begin  in  this  slow,  mild  way  if  the  infection 
originated  from  a  similar  discharge,  such  as  fairly  old  gleet  or  declining 


INVASION  OF  THE  TISSUES  BY  THE  GONOCOCCUS. 


27 


gonorrhoea,  in  which  it  takes  considerable  searching  with  the  microscope 
to  find  a  pns-cell  here  and  there  containing  gonococci. 

In  other  cases  a  severe  discharge,  purulent  from  the  beginning, 
occurs  suddenly  within  forty-eight  or  seventy-two  hours  after  the 
exposure.  In  such  a  case  as  this  we  may  suppose  that  a  very  large 
number  of  gonococci  enter  the  urethra  and  proliferate  extensively.  The 
initial  cocci  are  not  localized,  but  become  rapidly  distributed — perhaps 
at  the  exposure — over  a  large  surface  of  the  urethra,  and  exert  chemo- 
taxis,  or,  in  other  words,  produce  inflammation  simultaneously  at  many 
points  over  a  large  segment  of  the  urethra. 

Between  these  two  extreme  types  of  acute  and  mild  invasion  there 
are  all  sorts  of  intermediate  grades  of  the  incubation. 

Subacute  Invasion. — In  the  cases  of  long  incubation — where  there 
seem  to  be  but  few  gonococci  received  at  the  infection,  and  when  these 
remain  localized  for  a  few  days  before  proliferating  extensively  enough 
to  spread  over  a  considerable  part  of  the  urethra — an  exudation  really 
exists  during  the  whole  period  of  the  incubation.  This  exudation  in 
the  beginning  is  almost  a  microscopic  element ;  it  is  exceedingly  limited 
and  serous,  and  so  generally  escapes  attention  that  there  is  seldom  an 
opportunity  to  examine  it  microscopically.  After  two  or  three  or  sev- 
eral days  this  scanty  serous  exudation,  becoming  gradually  more 
copious,  suddenly  changes  and  becomes  a  purulent  discharge.  This 
sudden  change  indicates  the  period  when  the  gonococci  have  prolif- 

Fig.  3. 


Gonorrhoeal  discharge  in  the  early  days  of  infection  in  a  case  of  long  incubation,  showing  pave- 
ment epithelial  cells  on  which  a  few  gonococci  are  seated,  and  a  few  pus-cells  which  as  yet 
contain  no  gonococci. 


erated  and  become  extensively   enough   distributed  to  excite   general 
chemotaxis. 

In  the  very  beginning  of  the  prodromal  or  exudation  stage  ante- 
cedent to  the  onset  of  the  purulent  discharge  in  these  cases  of  slow 
incubation  there  is  simply  a  thin  or  sticky  nioistirre  of  the  walls  of  the 


28 


INVASION  OF  THE  TISSUES  BY  THE  GONOCOCCUS. 


urethra.  In  a  day  or  two  more  the  exudation  grows  more  natural,  and 
a  transparent  drop  the  size  of  two  or  three  pin-heads  may  be  forced  out 
of  the  meatus  by  gentle  pressure.  The  exudation  may  in  exceptional 
cases  stay  this  way  for  a  week.  Although  this  exudation  is  not  seen 
during  the  day,  it  appears  in  the  first  part  of  the  urine  as  scanty  lump- 
like masses.  The  discharge  is  best  seen  in  the  morning,  and  it  then 
looks  very  much  like  glycerin,  except  that  suspended  in  the  drop  are 
some  minute  translucent  and  whitish  flocculi,  like  tiny  particles  of  rice- 
seeds  or  suet,  A  little  later  the  drop  becomes  more  copious,  appears 
during  the  day,  and  is  mixed  with  whitish-yellow  streaks ;  then  per- 
haps, in  a  few  hours  or  within  a  day,  the  drop  may  change  suddenly 
and  radically,  when  it  becomes  entirely  yellow  and  creamy,  thick  and 
copious,  and  takes  on  the  characteristics  of  the  ordinary  purulent  dis- 
charge. 

Fig.  4. 


Showing  the  features  of  the  discharge  a  few  days  later  than  are  shown  in  Fig.  3.  The  epithelial 
cells  are  covered  by  an  increased  number  of  gonococci,  but  these  microbes  are  not  as  yet  con- 
tained in  the  substance  of  the  pus-cells,  which  are  rather  more  numerous. 

The  structural  features  of  the  discharge  in  this  early  stage  of  its 
development  in  these  cases  of  long  incubation  are  as  follows  :  The  exu- 
dation consists  largely  of  fluid  or  serum  containing  some  desquamated 
epithelial  cells,  and  later  on  only  a  scattered  pus-cell  here  and  there. 
In  the  early  stages  the  desquamated  epithelial  cells  predominate,  and  as 
the  exudation  progresses  the  pus-cells  become  more  numerous. 

It  is  the  desquamated  clusters  of  the  cells  lining  the  urethra  that 
produce  the  appearance  of  the  rice-like  or  suet-like  granules  in  the  clear 
drop.     Finally,  when  the  drop  suddenly  becomes  yellow,  the  epithelial 


INVASION  OF  THE  TISSUES  BY  THE  GONOCOCCUS. 


29 


cells  disappear  almost  entirely  or  are  overshadowed   by  the  enormous 
numbers  of  pus-cells. 

The  gonococci  in  this  stage  of  scanty  exudation,  before  the  regular 
discharge,  may  not  be  found  at  all  by  the  ordinary  cover-glass  staining 
tests.  If  the  incubation  is  very  slow,  they  may  be  found  at  first  in 
very  limited  numbers,  entirely  free  in  the  serous  fluid,  later  on  about  the 
edges  or  on  the  surface  of  the  epithelial  cells,  and  finally  exclusively  in 
the  pus-cells.   It  is  very  interesting  to  study  the  spreading  of  the  gonococci 

Fig.  5. 


Showing  the  features  of  the  discharge  in  confirmed  acute  gonorrhoea.    The  epithelium  has  wholly 
disappeared,  and  only  pus-cells  containing  many  gonococci  now  appear  in  the  field. 

over  the  surface  of  the  cell.  At  first  the  micro-organisms  may  be  seen 
only  on  the  edges  of  the  cell  ;  then  they  gradually  extend  until  they 
cover  its  whole  surface  like  a  sod,  perhaps  in  several  hours  or  perhaps 
in  a  day  or  two. 

Fig.  6. 


Gonorrhceal  discharge  obtained  a  few  hours  after  onset  of  disease,  containing  cylindrical  epithe- 
lium, pus-cells,  and  gonococci. 

It  is  important  to  remember  that  when  the  discharge  consists  only  of 
serum,  epithelial  cells,  and  gonococci  the  last-named  are  seated  on  the 
cells,  and  they  also  float  free  in  the  serum.  This  condition  also  may  be 
observed  where  a  few  pus-corpuscles  have  become  mixed  in  the  dis- 


30  INVASION  OF  THE  TISSUES  BY  THE  GONOCOCCUS. 

charge.  At  this  time,  therefore,  the  micro-organisms  may  be  present 
only  in  small  numbers  in  the  pus-cells,  or  they  may  not  be  thus  placed 
at  all.  Later  on,  when  the  discharge  becomes  decidedly  purulent,  the 
majority  of  the  gonococci  will  be  found  in  the  pus-cells,  and  very  few 
will  be  free  and  scattered  through  the  serous  fluid. 


Showing  enormous  quantities  of  gonococci  in  pus-cells  and  floating  free. 

The  behavior  of  gonococci  in  a  case  of  long  incubation  seems  to  be 
as  follows  :  The  gonococci  received  at  infection  are  too  few  to  be  gen- 
erally distributed  over  the  urethra,  and  hence  the  chemotaxis  they 
arouse  is  too  limited  to  appear  as  any  appreciable  exudation.  The 
cocci  seem  at  first  to  lie  free  on  the  surface  of  the  epithelium,  and  then 
they  work  their  way  down  between  the  surface  cells  to  the  deepest 
layer  of  urethral  lining  cells.  As  the  gonococci  thus  approach  the 
capillaries  beneath  the  epithelium,  chemotaxis  comes  into  play.  There 
is  at  first  a  slight  determination  of  leucocytes  from  the  blood-vessels, 
accompanied  by  some  serum  wThich  passes  out  into  the  urethra,  and 
synchronously  with  this  there  is  a  desquamation  of  the  epithelium 
lining  the  urethra. 

As  the  gonococci  become  more  and  more  numerous  and  are  distributed 
to  the  deeper  parts  of  the  urethra  in  virtue  of  its  capillary  attraction, 
there  comes  a  time  when  these  microbes  attract  the  leucocytes  from  a 
considerable  territory  of  the  canal  simultaneously,  and  this  corresponds 
to  the  time  when  the  discharge  suddenly  becomes  purulent  and  abun- 
dant, with  the  gonococci  enclosed  in  the  pus-cells. 

The  gonococci  are  found  in  the  pus-cells,  not  because  the  cocci  them- 
selves actively  penetrate  the  protoplasm,  as  has  been  erroneously  stated, 
but  because  the  leucocytes  act  as  phagocytes.  The  leucocytes  enclose 
the  cocci  by  virtue  of  their  amoeboid  properties,  and  carry  them  out  of 
the  urethra  in  the  purulent  discharge.  It  is  the  pus-cell,  in  all  proba- 
bility, which  carries  the  infecting  cocci  from  one  person  to  another,  and 


INVASION  OF  THE  TISSUES  BY  THE  GONOCOCCUS.  31 

probably  very  few  individuals  are  infected  by  gonococci  floating  about 
free  in  a  discharge. 

Acute  Invasion. — The  character  and  onset  of  the  cases  of  acute 
invasion  may  now  be  considered.  In  these  cases  the  number  of  the 
gonococci  received  at  the  exposure  is  so  large,  their  proliferation  is  so 
rapid,  or  they  become  so  soon  distributed — very  likely  at  the  exposure — 
over  a  large  surface  of  the  urethra,  that  the  discharge  may  be  seropuru- 
lent  or  purulent  from  the  beginning,  and  in  that  case  the  preliminary 
scanty  serous  exudation  previously  described  is  very  evanescent  or 
almost  entirely  absent.  It  happens  very  seldom  indeed  that  in  these 
cases  there  is  an  opportunity  to  examine  microscopically  the  evanescent 
serous  stage  of  such  a  discharge,  but  still  there  is  a  stage  of  desquama- 
tion of  the  urethral  epithelium  in  advance  of  the  purulent  discharge. 

The  desquamated  epithelium  appears  as  tiny  rice-colored  grains  in  a 
clear  exudation,  but  this  stage  of  desquamation  is  very  short  in  these 
acute  cases,  lasting  only  a  few  hours,  and  then  the  discharge  becomes 
purulent. 

As  a  general  rule,  the  long  incubation  of  gonorrhoea  is  best  marked 
in  cases  where  the  urethra  has  been  the  seat  of,  or  damaged  by,  previous 
attacks,  while  the  very  acute  invasion  often  is  best  exhibited  in  the 
virgin  or  normal  urethra.  In  previous  protracted  or  multiple  gonor- 
rhoeas there  is  a  tendency  toward  a  distinct  change  in  the  structure  of 
the  urethral  epithelium.  The  urethral  lining  in  places  becomes  thicker, 
and  the  surface  cells  become  flattened.  Pavement  epithelium  then 
replaces  the  cylindrical  variety.  To  what  extent  this  change  in  the 
urethral  epithelium  determines  the  long  incubation  often  seen  in  patients 
who  have  had  many  previous  gonorrhoeas  is  a  rather  difficult  question  to 
decide. 

The  Period  of  Incubation. — In  clinical  practice  it  is  found  that  the 
period  of  incubation  in  most  cases  is  from  three  to  seven  days  and 
exceptionally  it  is  two  days.  In  many  cases  ten  and  even  fourteen 
days  may  elapse  after  coitus  before  the  infection  is  demonstrated. 
Periods  of  incubation  of  fourteen  days  and  beyond  are  very  rare. 
Such  periods  of  incubation,  and  even  longer  ones  up  to  twenty  days, 
have  been  observed  in  patients  suffering  from  pneumonia,  typhoid  fever, 
and  erysipelas.  On  the  other  hand,  the  period  of  incubation  is  some- 
times made  shorter  by  prolonged  sexual  intercourse  and  alcoholic 
excesses. 

In  striking  contrast  with  this  virulent  infective  process,  with  its 
well-marked  period  of  incubation,  are  those  forms  of  purulent  ure- 
thritis due  to  the  passage  of  sounds  and  bougies  or  caused  by  strong 
injections,  in  all  of  which  the  discharge  comes  on  in  a  few  hours. 

The  Purulent  Stage  of  the  Disease.— When  the  discharge  has 


32  INVASION  OF  THE  TISSUES  BY  THE  GONOCOCCUS. 

once  commenced  and  becomes  tangible  and  yellow,  so  that  the  patient 
notices  it,  its  structural  characters  are  very  uniform.  It  consists  almost 
entirely  of  pns-cells  and  serum.  The  pus-cells  of  gonorrhoea  are  larger 
than  those  of  any  other  form '  of  suppuration.  Under  the  microscope 
with  a  moderate  power  the  pus-cells  can  be  seen  scattered  all  over  the 
field,  with  no  tendency  whatever  to  agglomeration  or  aggregation. 
Occasionally  in  the  beginning  of  the  purulent  stage  a  number  of  red 
blood-cells  appear,  with  finer  and  coarser  bands  or  sheets  of  fibrin. 
Occasionally  also  a  stray  rounded  or  oval  epithelial  cell  may  be  found 
here  and  there.  A  certain  proportion  of  the  pus-cells — say,  one  to 
twenty  or  one  to  fifty — contains  from  two  to  fifty  or  eighty  gonococci 
enclosed  in  their  cell-bodies. 

There  are  seldom  any  free  gonococci  except  in  the  earlier  stages  of 
the  purulent  period.  The  mode  of  invasion  of  the  urethra  by  staphyl- 
ococcus and  streptococcus  has  not  yet  been  studied. 

Features  of  the  Declining  Stage. 

As  the  purulent  stage  declines,  the  secretion  becomes  more  whitish 
from  the  admixture  of  mucus,  and  less  liquid.  Then  it  gradually  grows 
less  in  quantity  and  more  inspissated,  so  that  toward  the  end  of  the  acute 
stage  it  is  not  seen  as  a  secretion,  but  as  little  yellowish-white  clumps  or 
threads  in  the  urine.  Examination  of  the  secretion  of  this  stage  shows 
masses  of  pus-cells  held  together  somewhat  in  thread  form  by  mucus. 
This  condition  is  the  first  step  in  the  formation  of  the  gonorrheal  threads, 
called  by  the  Germans  tripper  faden. 

In  the  declining  period,  or  after  the  discharge  has  persisted  as  a  gleet 
for  some  days  or  weeks,  it  still  consists  of  pus-cells,  less  thickly  aggre- 
gated, and  entangled  in  sheets  of  fibrin  or  mucus,  with  a  variable  number 
of  rounded  epithelial  cells.  In  this  stage  healing  of  the  mucous  mem- 
brane usually  begins.  The  hyperemia  gradually  grows  less,  the  morbid 
surface  becomes  contracted,  lessened  in  area,  and  a  tendency  is  observed 
to  render  the  surface  of  the  mucous  membrane  normal.  In  this  process 
exulcerations  and  eroded  spots,  caused  by  the  gonorrhoea,  become  more 
or  less  completely  covered  by  an  epithelial  coating.  As  this  salutary 
epithelial  proliferation  goes  on  there  is  much  desquamation,  as  well  as 
the  escape  of  serum  and  leucocytes  from  the  membrane.  It  thus  hap- 
pens that  a  larger  or  smaller  number  of  epithelial  cells  are  found  in  a 
gleety  discharge.  With  the  appearance  of  epithelial  scales  the  repara- 
tive process  may  be  said  really  to  begin,  and  as  the  case  progresses  the 
pus-cells  become  less  and  less  numerous,  while  the  epithelial  cells  in- 
crease in  number.  Then,  if  all  goes  well,  these  cells  gradually  grow  less 
numerous,  and  a  cure  results.  It  follows,  therefore,  when  in  a  declining 
gonorrhoea  pus-cells  persist  in  great  numbers,  while  epithelial  cells  are 


FEATURES  OF  THE  DECLINING   STAGE. 


33 


scanty,  that  there  is  slow  progress  toward  cure.  Then,  on  the  other  hand, 
when  frequent  examinations  show  that  the  pus-cells  are  disappearing  and 
that  the  epithelial  cells  preponderate,  it  is  evident  that  the  morbid  proc- 
ess is  ceasing.  As  in  the  early  stages,  so  in  the  later  ones,  the  micro- 
scope gives  us  great  aid  in  determining  the  character  and  extent  of  the 
inflammatory  process.  In  these  later  stages  the  discharge  is  commonly 
so  scanty  that  it  does  not  escape  from  the  meatus,  but  it  is  carried  from 
the  canal  by  the  stream  of  urine.  This  discharge  is  then  seen  to  be  in 
the  form  of  clumps  rounded,  irregular,  or  crab-like,  in  the  form  of  flakes 
of  various  size  and  irregular  shapes,  and  in  the  form  of  threads  which 
may  be  long  and  very  thin  or  thick  or  short  and  stumpy.  The  threads 
from  either  the  anterior  or  posterior  portion  of  the  urethra  have  the  same 
microscopical  structure  as  the  gleety  drop  ;  they  are  composed  quite  con- 
siderably of  pus-cells  entangled  in  a  thick  fluid  exudation  containing 
fibrin  or  mucus  and  generally  a  variable  number  of  epithelial  cells. 

Gonorrheal  Threads. — Gonorrheal  threads,  or  urethral  filaments, 
may  be  divided  into  four  quite  distinct  varieties.  First,  there  is  the  pus- 
thread.  The  second  is  the  gelatinous  thread.  The  third  is  a  firm  thread, 
consisting  of  pus,  mucus,  round,  and  epithelial  cells,  and  indicative  of  a 
well-developed  chronic  exudative  process.  The  fourth  form  of  thread 
consists  chiefly  of  epithelium,  with  very  little  pus,  and  some  basement 
mucin  to  hold  the  cell-elements  together. 


Fig.  8. 


Showing  a  thread-like  agglomeration  of  pus-cells  held  together  by  mucin,  being  the  first  stage  in 

the  formation  of  the  thread 

The  first  form  or  pus-thread  is  pictured  in  Fig.  8.  It  is  a  thread 
only  in  the  sense  of  pus-cells  being  agglutinated  with  each  other  or 
strung  together  by  means  of  mucin  as  a  basement-substance.     It  may 


34 


INVASION  OF  THE  TISSUES  BY  THE  GONOCOCCUS. 


be  in  the  form  of  threads,  clumps,  and  irregular  masses.     This  product 
is  observed  just  before  the  appearance  of  epithelia  in  the  threads. 

The  gelatinous  threads  are  seen  most  commonly  toward  the  end  of 
the  acute  stage,  when  mucin  comes  to  be  secreted  and  acts  as  a  cement- 
substance  for  the  cellular  exudation.  These  gelatinous  threads  are  also 
not  uncommonly  seen  late  in  the  course  of  gonorrhoea  when  the  exuda- 
tive process  still  lingers  in  the  submucous  connective  tissue  and  the  over- 
lying membrane  is  in  a  catarrhal  condition.  These  gelatinous  threads 
are  sometimes  finer  than  the  finest  hair,  and  are  of  intermediate  sizes 


Mucin,  pus,  and  epithelium. 


FlG.  10. 


Showing  gelatinous  thread  with  pus-cells,  round  hyaline  (iodophilous)  cells,  epithelial  cells  held 
together  by  mucin;  declining  stage  of  acute  gonorrhoea. 

until  the  dimensions  of  a  knitting-needle  are  reached.  They  are  often 
very  long  (three,  four,  and  more  inches),  and  float  about  in  the  urine  in 
graceful  curves.  Then,  again,  they  are  thicker,  less  lengthy,  and  per- 
haps of  irregular  calibre.  They  are  usually  very  elusive,  and  are  with 
difficulty  captured  by  the  pipette  or  the  forceps,  and  when  caught  they 
collapse  into  a  little  gelatinous  mass.  In  this  form  of  thread  we  find 
entangled  in  the  cement-substance  pus-cells,  round-cells,  and  perhaps 
some  large  flat  epithelial  cells.  This  form  of  thread  is  usually  seen  to 
follow  the  pus-thread  already  pictured  in  Fig.  8,  in  which  no  epithelium 
is  yet  present,  and  which  is  symptomatic  of  the  turning-point  in  the 
acute  stage  of  the  disease.  With  these  gelatinous  threads  there  is  fre- 
quently such  an  amount  of  mucus  as  to  render  the  urine  cloudy,  though 


FEATURES  OF  THE  DECLINING  STAGE. 


35 


not  opaque,  and  very  often  to  look  like  mucilage  diluted  with  water,  or 
new  cider.    The  microscopical  appearances  are  shown  in  Figs.  9  and  10, 

The  third  form  of  urethral  filaments  consists  of  whitish-gray  and 
brownish-white  threads,  varying  in  length  from  a  third  of  an  inch  to  an 
inch  and  more  in  length.  They  may  be  thread-like,  thin,  and  delicate 
or  thick  and  stumpy.  Some  have  a  distinct  head,  and  resemble  a  comma, 
and  are  said  to  come  from  the  posterior  urethra.  Then,  again,  they 
present  branched  forms,  and  some  resemble  crabs  in  shape.  Indeed, 
words  fail  to  describe  all  the  shapes  assumed  by  these  urethral  exudates. 
Examined  under  the  microscope,  these  pathological  products  are  found 
to  consist  of  round  cells,  hyaline  cells  readily  colored  with  iodine  (iodoph- 
ilous),  pus-cells,  epithelial  cells,  oval,  polygonal,  irregular,  fusiform, 
and  caudate.  All  these  elements  are  held  together  in  the  most  complete 
disorder  as  to  arrangement  by  the  basement-substance.  In  Fig.  1 1  is 
well  portrayed  the  appearance  of  the  discharge  in  chronic  gonorrhoea  of 
the  bulb,  and  its  study  will  give  a  clear  idea  of  the  microscopical  picture. 

The  scaly  threads  or  flakes  which  form  the  fourth  variety  are  less 
common  than  the  threads  just  described.  They  may  be  seen  in  the  form 
of  a  coarse  powder,  in  threads,  in  lumps,  and  flakes  of  whitish-gray 
color.  They  are  firm  in  structure,  and  readily  sink  to  the  bottom  of  the 
glass.  Examined  with  the  microscope,  these  flakes  show  a  quite  uni- 
form field  of  flat  epithelium  in  various  shapes,  which  shows  stability  of 
structure.     Many  of  these  cells  are  nucleated,  and  not  infrequently  they 

Fig.  11. 


Showing  secretion  of  declining  acute  anterior  gonorrhoea. 

are  the  seat  of  fatty  degeneration.  There  are  usually  some  pus-cells 
intermixed  in  the  field.  This  form  of  thread  or  flake  (well  shown  in 
Fig.  12)  is  usually  the  product  of  a  localized  inflammatory  process  in  the 
anterior  urethra  as  far  down  as  the  bulb.     It  is  usually  indicative  of  an 


36  INVASION  OF  THE  TISSUES  BY  THE  GONOCOCCUS. 

erosion  or  ulcer  in  which  the  reparative  process  is  abortive,  and,  although 
new  epithelium  is  formed,  the  integrity  of  the  mucous  membrane  is  not 

Fig.  12. 


Showing  epithelium  and  pus  from  localized  morbid  area. 

re-established.  On  finding  such  a  microscopical  picture  one  is  war- 
ranted in  making  an  endoscopic  examination  with  a  view  of  localizing 
the  morbid  area. 

In  stricture  of  the  urethra  the  third  and  fourth  varieties  of  threads 
are  usually  found,  together  with  more  or  less  pus  and  mucus. 

Fig.  13. 


Showing  secretions  of  posterior  urethritis  in  chronic  stage. 

Attempts  have  been  made  without  success  to  establish  sharply-marked 
differences  in  the  microscopical  pictures  of  the  discharge  in  anterior  and 
posterior  gonorrhoea.  The  truth  is,  that  in  the  main  there  are  the  same 
cellular  elements  to  be  seen  in  the  discharge  from  the  anterior  urethra. 


DISAPPEARANCE   OF  THE  GONOCOCCUS.  37 

as  are  found  in  that  of  the  posterior  urethra  in  chronic  gonorrhoea. 
Consequently,  in  many  cases  the  microscope  affords  little  help  in  deter- 
mining exactly  where  a  discharge  comes  from,  but  it  generally  gives  a 
good  idea  of  the  condition  of  the  process.  In  some  cases,  however,  we 
find  dead  spermatozoa  inextricably  mixed  up  among  the  cell-groups,  and 
thus  we  have  presumptive  evidence  that  the  morbid  focus  is  in  the  pos- 
terior urethra.  But  even  in  this  event  a  positive  conclusion  cannot  be 
reached  until  it  has  been  proven  that  the  seminal  vesicles  are  not  affected, 
since  the  same  microscopical  picture  may  be  presented  in  seminal  vesi- 
culitis. In  Fig.  13  the  appearances  of  the  discharge  from  the  posterior 
urethra  are  well  shown.  There  is  much  resemblance  to  the  picture  pre- 
sented by  the  discharge  from  the  anterior  urethra  already  shown.  (See 
Fig.  11.)  But  it  will  be  seen  that  there  are  many  spermatozoa  scattered 
and  in  clumps,  and  that  the  round  cells  are  present  in  rather  greater 
numbers. 

These  appearances  of  the  morbid  cellular  elements  in  anterior  and 
posterior  gonorrhoea  may  be  seen  months,  and  even  years,  after  the  onset 
of  the  infection.  In  other  words,  in  chronic  cases  the  morbid  process 
gives  rise  quite  uniformly  to  the  same  orders  of  pathological  products. 

Disappearance  of  the  Gonococcus. 

As  a  general  rule,  the  gonococcus  gradually  ceases  in  the  gleety  morn- 
ing drop  and  in  the  threads.  It  becomes  extinct  and  disappears  out  of 
the  urethra,  yet  the  gleet  and  threads  still  persist,  but  this  is  because  of 
certain  structural  changes  in  the  urethra  left  behind  by  the  severe  exu- 
dative inflammation  caused  by  the  gonococcus.  All  sorts  of  bacteria 
may  be  found  in  the  threads  and  often  in  old  gleets,  and  among  them 
several  diplococci  which  resemble  or  look  almost  exactly  like  the  gono- 
coccus ;  also  long  and  thin  and  short  and  thick  bacilli.  In  fact,  by  the 
microscope  alone  it  is  almost  impossible  to  positively  identify  the  gono- 
coccus in  old  gleet,  or  threads ;  consequently,  it  is  well  to  be  skeptical 
and  perhaps  incredulous  as  to  statements  of  authors  that  they  have  found 
this  microbe  under  these  conditions. 

The  discharge  persists  after  the  extinction  of  the  gonococcus  because 
of  the  ulcers,  erosions,  small  round-cell  residues,  and  thickening  beneath 
the  epithelium,  or  other  sequelae  incident  to  the  intense  exudative  inflam- 
mation aroused  by  the  gonococcus.  An  ulcer  or  exulceration,  especially 
in  a  long,  narrow,  closed  sinus  like  the  urethra,  will  continue  to  exude 
indefinitely  without  any  assistance  of  the  gonococcus. 

Etiology. — It  has  been  clearly  shown  in  the  foregoing  pages  that  the 
gonococcus  is  the  materies  morbi  of  gonorrhoea  in  the  vast  majority  of 
cases,  and  that  in  exceptional  instances  other  pyogenic  microbes  are  the 
factors  of  infection. 


38  INVASION  OF  THE  TISSUES  BY  THE  OONOCOCCUS. 

There  can  be  no  doubt,  therefore,  that  many  men  contract  gonorrhoea 
from  women  suffering  from  a  specific  gonococcus-infection  of  some  part 
of  their  genital  tract ;  and,  on  the  other  hand,  women  are  infected  by 
men  similarly  infected  in  their  urethra.  But  there  is  met  with,  particu- 
larly in  private  practice  among  respectable  people,  a  class  of  cases  in  which 
men  contract  gonorrhoea  from  women  who  claim  to  be  and  seem  to  be 
perfectly  healthy.  The  latter  state  that  they  never  had  the  classical 
symptoms  of  gonorrhoea,  and  prior  to  the  infecting  coitus  and  after  it 
considered  themselves  perfectly  healthy.  Many  of  the  men  thus  affected 
have  not  true  gonorrhoea,  but  a  discharge  resulting  from  an  exacerbation 
of  a  dormant  chronic  urethritis. 

Then,  again,  many  women  suffering  from  leucorrhoea  or  some  disease 
of  their  sexual  organs  (and  in  whom  no  gonococci  can  be  found)  com- 
municate true  gonorrhoea  to  men  in  sexual  intercourse.  In  some  instances 
men  contract  the  disease  from  seemingly  healthy  women  in  coitus  during 
or  just  after  the  menstrual  epoch.  All  these  cases  puzzle  us  very  much, 
and  the  fact  is  that  though  we  know  much  about  the  gonococcus,  the 
etiology  of  gonorrhoea  is  to-day  in  a  very  unsettled  state. 

According  to  doctrines  now  largely  prevailing,  the  gonococcus  in  the 
male  is  presumptive  evidence  of  guilt  of  the  woman.  Such  a  doctrine 
is  too  absolute,  and  even  cruel,  and  may  be  the  cause  of  much  unhappi- 
ness,  suffering,  and  misery.  This  question  often  may  involve  the  virtue 
of  wives  and  the  loyalty  of  mistresses,  and  demands  our  earnest  atten- 
tion. In  all  such  cases  the  accused  should  receive  the  benefit  of  any 
doubt  which  may  exist ;  and  the  physician  who  withholds  it  from  her  out 
of  a  morbid  fear  that  he  may  be  imposed  upon,  and  thus  runs  the  risk 
of  convicting  an  innocent  person,  is  unworthy  of  his  calling.  His 
province  is  to  decide  from  the  symptoms,  taken  in  connection  with  the 
known  facts  of  the  case,  and  unless  these  are  sufficient  to  establish  guilt 
beyond  the  shadow  of  a  doubt  humanity  demands  at  least  a  verdict  of 
"  not  proven."  (For  a  thorough  discussion  of  this  subject  see  my  work, 
The  Pathology  and  Treatment  of  Venereal  Diseases,  Philadelphia,  1895, 
pp.  85  et  seq.) 


CHAPTER    III. 

ACUTE  ANTERIOR  AND  POSTERIOR  GONORRHOEA, 
OR  URETHRITIS. 

Prodromal  Stage. — At  the  end  of  the  period  of  incubation  the 
symptoms  of  acute  anterior  gonorrhoea  manifest  themselves.  These 
may.be  quite  severe  or  they  may  be  mild.  Patients  usually  complain 
of  a  tickling,  pricking,  and  itchy  sensation  at  the  meatus  or  in  the  fossa 
navicularis.  These  sensations  may  be  accompanied  by  a  feeling  of  more 
or  less  heat  in  the  parts.  Then,  again,  in  some  cases  decided  uneasiness, 
bordering  on  pain,  is  felt,  which  may  be  spontaneous  and  continuous  or 
felt  only  during  and  after  urination.  The  intensity  of  these  early  symp- 
toms of  acute  gonorrhoea  very  often  depends  largely  on  the  nature  of  the 
patient.  A  nervous,  worrying  subject  complains  more  or  less  strongly ; 
while  an  ignorant,  apathetic,  or  obtuse  one  may  make  no  complaint 
whatever.  We  not  infrequently  see  patients  who  positively  state  that 
the  discharge  is  the  first  symptom  known  to  them. 

Inspection  of  the  meatus  in  the  prodromal  stage  shows  it  to  be  slightly 
reddened,  glazed,  and  perhaps  coated  with  a  film  of  colorless,  grayish,  or 
opaline  mucus,  in  which  a  few  minute  whitish  flakes  or  suet-like  lumps 
are  mixed.  This  fluid  is  usually  quite  scanty,  but  sometimes  one  or  more 
drops  may  be  expressed  from  the  canal.  It  grows  more  copious  as  time 
advances.  Frequently  this  secretion  produces  a  gluing  together  of  the 
lips  of  the  meatus  in  the  intervals  of  urination,  which  act  may  be  thereby 
impeded  for  a  few  moments.  This  symptom  of  gluing  together  of  the 
lips  of  the  meatus  is  frequently  the  first  sign  the  patient  has  of  his 
oncoming  disease. 

In  this  stage  the  urine  is  clear  and  free  from  mucus,  but  on  agitation 
a  few  minute  gray  flakes  or  minute  lumps  may  be  seen.  In  other  words, 
a  few  infected  epithelial  cells  float  in  healthy  urine. 

In  some  cases  the  infective  process  of  gonorrhoea  at  the  onset  is  quite 
slow  in  development,  and  very  little  disturbance  may  be  noted  at  the 
meatus  for  several  days.  As  a  rule,  after  the  lapse  of  one,  two,  or  three 
days  a  decided  state  of  inflammation  is  seen.  The  lips  of  the  meatus 
become  swollen  and  perhaps  pouting,  and  the  redness  invades  the  glans 
penis  in  a  disk-like  form  around  the  meatus.  The  mucous  secretion 
becomes  increased  in  quantity,  then  assumes  a  decidedly  opalescent  hue, 
from  which  it  is  rapidly  transformed  into  a  milky-looking  fluid,  and 

39 


40  ACUTE  ANTERIOR   GONORRHOEA. 

then  into  true  greenish  pus.  A  decided  smarting  or  burning  pain, 
called  ardor  urinse,  is  then  felt  in  the  fossa  navicularis,  particularly 
during  urination  and  sometimes  continuously. 

The  irritation  incident  to  the  prodromal  stage  being  limited  to  the 
distal  part  of  the  penis  frequently  gives  rise  to  a  condition  of  erethism 
in  that  organ,  which  remains  in  a  state  of  incomplete  erection.  Desire 
for  coitus  is  sometimes  so  urgent  and  uncontrollable  that  sexual  excesses 
are  committed  and  masturbation  is  practised,  much  to  the  aggravation 
of  the  disease.  The  symptoms  of  acute  anterior  gonorrhoea  in  its  pro- 
dromal stage  are  strictly  local  in  character. 

With  the  onset  of  the  classical  symptoms  of  true  inflammation — 
namely,  redness,  swelling,  pain,  and  pus — the  prodromal  stage  is  said  to 
end  and  the  acute  or  florid  stage  to  begin. 

The  Acute  Stage. — The  redness,  previously  limited  to  the  halo-like 
disk  around  the  meatus,  may  spread  and  involve  the  whole  glans,  which 
then  becomes  swollen.  Then,  particularly  in  cases  in  which  the  prepuce 
is  long  and  tight,  this  mucotegumentary  covering  becomes  red  and 
swollen  in  part  or  in  its  entirety.  As  a  result  oedema  may  be  produced, 
which  may  be  limited  to  the  region  of  the  fossa?  of  the  frsenuni  or  it  may 
involve  the  distal  part  of  the  prepuce.  In  very  severe  cases  it  attacks 
the  whole  integument  of  the  penis,  and  thereby  causes  much  pain,  ten- 
sion, and  discomfort.  Frequently  very  little  oedema  is  present,  but  we 
may  find  the  lymphatics  on  either  side  of  the  frsenum  swollen,  and  can 
trace  them  as  small,  red,  tender  cords  along  the  dorsum  of  the  penis  to 
the  lymphatic  ganglia  in  the  groin,  which  may  be  more  or  less  swollen 
and  painful.  In  general,  adenitis  in  acute  gonorrhoea  is  of  rather  mild 
character,  and  it  subsides  in  a  few  days,  particularly  if  the  patient  can  go 
to  bed.  In  some  cases,  however,  abscess-formation  occurs  and  an  inflam- 
matory bubo  results.  (See  Plate  II.)  Xot  infrequently  phimosis  is 
induced,  which  much  distorts  the  shape  of  the  penis.  Then,  again, 
paraphimosis  is  a  not  infrequent,  painful,  and  disquieting  complication. 
(See  sections  on  Phimosis  and  Paraphimosis.)  The  discharge  is  then 
profuse,  thick,  creamy,  and  decidedly  purulent,  and  sometimes  mixed 
with  blood.  This  condition  of  affairs,  which  is  usually  reached  toward 
the  end  of  the  first  or  early  in  the  second  week,  and  perhaps  earlier, 
is  attended  by  the  extension  of  the  disease  down  the  urethra,  per- 
haps as  far  as  the  bulb.  Then  in  severe  cases  the  corpus  spongio- 
sum can  be  felt  as  a  swollen,  hard,  cord-like  tube  that  is  painful  to  the 
touch.  Occasionally  we  may  detect  along  the  course  of  this  corpus 
spongiosum  one  or  more  swellings  or  periurethral  nodules  of  the  size 
of  small  shot  or  of  a  pea,  which  are  simply  inflamed  follicles.  They 
show,  however,  that  the  gonorrhceal  process  has  involved  the  whole 
thickness  of  the  mucous  membrane,  and  has  attacked  the  meshes  of  the 
corpus  spongiosum.     In  cases  presenting  this  intensity  of  symptoms  the 


PLATE   II. 


ACUTE  GONORRHOEA,  ABSCESS   AND   INFLAMMATORY   ADENITIS. 


THE  ACUTE  STAGE.  41 

whole  thickness  of  the  raucous  membrane,  the  subcutaneous  connective 
tissues,  and  the  erectile  tissue  of  the  corpus  spongiosum  are  involved. 
In  these  cases  the  gonorrhoeal  process  has  extended  deeply  ;  but  there  are 
cases  in  which  the  symptoms  are  very  severe,  but  in  which  this  depth 
of  invasion  of  the  inflammatory  process  cannot  be  made  out,  since  the 
spongy  urethra  does  not  feel  very  much  swollen.  These  are  instances 
in  which  the  gonorrhoeal  process  is  superficial  and  invades  the  mucous 
membrane  and  the  submucous  coat  only  slightly  ;  such  cases  are  not 
at  all  uncommon.  As  a  result  of  this  inflammatory  swelling  of  the 
mucous  and  submucous  tissues  the  calibre  of  the  urethral  canal  is  very 
much  narrowed.  Urination  then  becomes  an  act  of  pain,  and  even  of 
agony,  by  reason  of  the  induced  scalding  and  burning  sensations, 
described  by  some  as  if  a  hot  iron  had  been  introduced  into  the  canal, 
which  may  be  felt  along  the  whole  of  the  pendulous  urethra  or  may 
be  most  severe  at  the  fossa  navicularis.  Sometimes  the  pain  is  said  to 
be  at  the  penoscrotal  angle,  and  at  others  as  far  as  the  bulb.  The 
patient  dreads  to  void  his  urine,  and  ventures  to  do  so  as  seldom  as 
possible. 

This  burning  pain  on  urination  is  due  to  the  forcible  distention  of  the 
inflamed  and  suppurating  urethra,  and  also  to  the  acid  condition  of  the 
urine.  A  further  result  of  this  mechanical  narrowing  of  the  canal  is 
seen  in  the  character  of  the  stream  of  urine.  This  becomes  hesitating, 
weak,  sputtering,  forked,  twisted,  narrow,  and  wiry,  and  the  urine  may 
even  escape  by  drops.  All  the  shapes  of  the  stream  of  urine  produced 
by  stricture  may  be  simulated  in  the  acute  stage  of  gonorrhoea.  At  this 
time  a  patient's  suffering  during  urination  may  be  still  more  intensified 
by  spasmodic  contractions  of  the  compressor  urethras  muscle,  which  not 
infrequently  causes  painful  strangury. 

Very  often,  both  in  the  acute,  declining,  and  chronic  stages  of  gonor- 
rhoea, patients  complain  of  dribbling  of  urine  on  their  linen  for  a  few 
minutes  after  each  urination.  This  condition  is  due  to  loss  of  the 
resiliency  of  the  urethral  canal,  which  by  its  contraction  aids  in  the  final 
expulsion  of  the  last  drops.  The  urethral  walls  are  so  swollen  and 
oedematous  that  their  muscular  fibres  have  lost  their  tonus. 

It  must  not  be  forgotten  that  in  uncomplicated  acute  anterior  gonor- 
rhoea there  is  usually  not  much,  if  any,  increased  desire  to  urinate. 
Such  patients  can,  as  a  rule,  hold  their  water  nearly  as  well  as  they  did 
in  health. 

The  acme  of  this  acute  stage,  which  is  reached  usually  in  the  second 
week,  is  attended  with  a  still  more  unpleasant  train  of  symptoms.  The 
urethra  is  then  involved  from  the  meatus  to  the  bulb.  The  pendulous 
urethra  is  sensitive,  and  even  painful,  and  when  the  disease  is  located  at 
the  bulb  there  is  a  sensation  of  tightness,  and  even  anguish,  between  the 


42  ACUTE  ANTERIOR   GONORRHOEA. 

testes ;  walking  is  rendered  uncomfortable  and  sudden  jarring  causes 
much  pain.  When  such  patients  attempt  to  sit  down  they  go  about  it 
slowly  and  carefully  and  avoid  pressure  upon  the  perineum.  They  are 
also  careful  in  crossing  their  legs  lest  they  should  suifer  thereby. 
Besides  these  pains  in  the  penis  and  perineum,  there  may  be  a  more  or 
less  uneasy  aching  and  dragging  pain  in  the  testes,  and  also  in  the  groins 
and  lumbar  region.  As  a  consequence  of  all  this  suffering  some  patients 
become  really  ill,  and  they  look  pale,  worried,  and  hollow-eyed,  lose 
their  appetites,  feel  weak,  and,  in  short,  suffer  from  malaise  and  mental 
depression.  Some  patients  have  a  mild  or  pronounced  fever,  accompa- 
nied by  chilliness,  especially  toward  night.  While  such  patients  suffer 
much  during  the  day,  they  frequently  endure  much  discomfort,  and  even 
torture,  during  the  night.  Insomnia  is  not  infrequently  experienced  as 
the  result  of  painful  erections,  accompanied  by  debilitating  pollutions, 
and  also  by  chordee. 

In  this  acute  stage  we  often  see  a  peculiar  form  of  hematuria. 
Toward  the  end  of  urination  or  a  short  time  thereafter  a  few  drops  of 
blood  may  escape  from  the  urethra.  Sometimes  this  does  not  occur  until 
after  the  patient  has  replaced  his  penis  under  his  clothes,  which  he  sub- 
sequently finds  stained.  This  postmictional  hematuria  is  due  to  com- 
pression of  the  inflamed  mucous  membrane  by  the  accelerator  urinse 
muscle  and  to  its  forced  distention  by  the  stream  of  urine. 

In  most  patients  the  purulent  discharge  is  more  profuse  in  the 
morning,  from  which  time  it  diminishes  in  quantity  till  night,  when  it 
reaches  its  minimum.  This  condition  is  largely  due  to  the  less  fre- 
quency in  urination  during  the  night,  when,  of  course,  the  secretion 
accumulates  in  the  canal.  It  is  also  due  in  many  cases  to  nocturnal 
exacerbation  of  the  disease,  resulting  undoubtedly  largely  from  exercise 
taken  and  exertion  made  on  the  day  previous.  When  patients  remain 
in  bed  the  exacerbation  and  remission  of  symptoms  are  usually  very 
much  less  marked. 

This  ensemble  of  morbid  phenomena,  inflammatory  and  subjective, 
is  generally  complete  toward  the  end  of  the  second  or  early  in  the  third 
week,  and  its  further  duration  depends  largely  upon  the  hygiene,  regi- 
men, diet,  and  treatment  of  the  patient.  If  rest  and  quiet  can  be 
obtained  and  proper  medication  is  followed,  the  patient's  condition  will 
begin  to  mend  at  this  time.  The  first  noticeable  feature  of  improve- 
ment is  a  diminution  in  the  patient's  sufferings,  particularly  during 
urination.  Then  he  will  be  progressively  less  troubled  with  his  painful 
nocturnal  symptoms,  and,  as  a  result,  he  will  sleep  better  and  will  feel 
stronger  and  more  cheerful.  His  appetite  will  become  better  and  his 
general  morale  will  be  improved. 

In  some  cases,  however,  pain,  soreness,  or  a  burning  sensation   on 


DURATION  OF  ATTACK.  43 

urination  persists  after  all  other  symptoms  have  become  ameliorated  or 
have  even  disappeared. 

The  symptomatic  pains  and  uneasiness  in  the  testes,  loins,  and  groins 
will  become  markedly  less  severe.  The  redness  (and  swelling,  if  pres- 
ent) about  the  glans  and  prepuce  will  subside,  the  meatus  will  appear 
more  normal  in  color  and  in  shape,  and  the  corpus  spongiosum  will  be 
much  less  tense,  swollen,  and  painful.  Then,  owing  to  the  as  yet  par- 
tial subsidence  of  the  swelling  of  the  urethral  mucous  membrane,  the 
stream  of  urine  will  become  stronger  and  larger.  The  discharge  is  at 
this  time  usually  copious,  but  it  insensibly  grows  less  green  and  becomes 
more  milky  and  mucoid.  Its  quantity  then  decreases,  and  it  gradually 
grows  thinner  in  consistence.  Thus  it  slowly  disappears  under  favor- 
able circumstances  until  only  a  little  grayish  mucopus  may  be  seen 
during  the  day,  or  it  may  be  only  visible  in  the  morning,  when  it  glues 
the  lips  of  the  meatus  together.  This  condition  may  remain  for  a  few 
or  several  days,  and  then,  if  treatment  is  followed,  no  discharge  can  be 
seen  and  the  urethra  seems  again  in  a  normal  condition. 

The  foregoing  description  applies  only  to  cases  of  anterior  gonor- 
rhoea, in  which  the  morbid  process,  as  already  stated,  stops  at  the  tri- 
angular ligament.  In  many  such  cases,  unfortunately,  toward  the  end 
of  the  first  and  in  the  second  week  the  suppurative  process  extends  to 
the  posterior  urethra,  and  a  new  order  of  phenomena,  to  be  described 
later  on,  is  ushered  in.  In  this  event  the  suppurative  process  in  the 
anterior  urethra  may  cease  entirely  or  it  may  smoulder  in  a  subacute 
form. 

Mild  Course. — It  must  be  clearly  borne  in  mind  that  the  foregoing 
symptom-complex  is  that  presented  by  a  severe  form  of  acute  anterior 
gonorrhoea,  and  that  there  are  milder  forms  in  which  the  gonorrhoeal 
process  is  less  intense  and  the  symptoms  less  severe.  Thus  the  pain  or 
burning  on  urination  may  amount  to  only  a  mild  sensation  of  heat  or  a 
slight  pricking  or  smarting.  Erections  may  be  attended  with  little  if 
any  discomfort,  and  interfere  but  little  with  the  patient's  sleep.  There 
is,  therefore,  less  heat  in  the  canal  and  the  erethism  is  mild  or  absent. 

We  constantly  see  cases  of  primary  anterior  gonorrhoea  in  which, 
though  the  purulent  discharge  is  profuse,  even  sanguinolent,  the  inflam- 
matory symptoms  are  not  strongly  marked  and  the  patient's  suiferings 
are  correspondingly  mild.  Indeed,  we  see  cases  of  profuse  discharge  in 
which  patients  make  little  if  any  complaint,  though  the  inflammatory 
phenomena  seem  well  marked.  This  may  also  be  observed  in  cases  in 
which  the  symptoms  have  been  acute  and  intense. 

Duration  of  Attack. — In  favorable  cases  of  acute  anterior  urethritis 
a  cure  may  be  brought  about  in  from  four  to  six  weeks,  in  which  event 
the  patient  may  consider  himself  a  very  lucky  man.     We  occasionally 


44  ACUTE  ANTERIOR   GONORRHOEA. 

see,  however,  some  patients  get  well  in  three  or  four  weeks.  These 
favorable  cases  generally  are  instances  of  the  result  of  careful  hygiene 
and  discreet  regimen,  combined  with  judicious  and  efficient  treatment. 
In  private  practice  it  is  very  often  impossible  to  place  patients  at  rest, 
and  they  thereby  are  unable  at  first  to  avail  themselves  of  one  of  the 
most  important  means  of  cure.  Even  in  hospitals  it  is  a  most  difficult 
task  to  keep  such  patients  in  bed.  Therefore,  in  a  large  number  of  cases 
gonorrhoea  runs  on  in  patients  who  cannot  follow  the  requirements  of 
strict  regimen,  hygiene,  and  treatment.  As  a  result  the  acute  stage 
passes  into  the  subacute,  or  declining,  stage,  which  may  last  many 
months.  In  such  cases  the  more  or  less  scanty  or  copious  discharge 
is  the  most  prominent  symptom. 

Relapses. — In  the  declining  stage  annoying  relapses  are  quite  fre- 
quent. Sometimes  these  relapses  are  mild,  and  again  they  are  severe 
in  character.  They  usually  grow  less  and  less  severe,  and  then  a  cure 
follows.  Most  instances  of  relapse  are  due  to  the  carelessness  and  heed- 
lessness of  the  patient,  who  indulges  in  alcoholics  and  highly-seasoned 
food,  in  venery,  and  in  active  exercise.  Very  often  the  abstinence  from 
sexual  intercourse  necessitated  by  the  gonorrhoea  induces  a  condition 
of  erethism  in  the  patient,  which  gives  rise  to  nocturnal  emissions  and 
brings  on  a  relapse.  Then,  again,  the  tissues  of  some  patients  seem 
prone  to  become  inflamed  and  slow  to  return  to  a  normal  condition,  and 
in  such  subjects  relapses  are  common. 

It  is  usually  in  the  course  of  or  as  a  result  of  these  relapses,  after 
first  and  later  infections,  that  the  gonorrhoea!  process  seems  to  localize 
itself  in  certain  portions  of  the  urethra — namely,  the  bulbous  portion, 
the  spongy  portion,  at  the  penoscrotal  angle,  the  portion  of  the  urethra 
immediately  anterior  to  this,  and  in  the  fossa  navicularis.  In  many 
cases  a  latent  inflammation  remains  in  one  or  more  of  the  urethral 
crypts  and  follicles.  Then  external  irritation  develops  this  chronic  con- 
dition into  an  active  stage,  when  a  greater  or  less  segment  of  the  urethra 
becomes  involved.  It  is  to  the  chronicity  of  the  morbid  process  that 
the  development  of  stricture  of  the  urethra  is  due. 

Many  patients  regard  these  relapses  at  periods  more  or  less  remote 
from  the  original  infection  as  new  infections.  They  are  really,  in  many 
instances,  ephemeral  suppurations  induced  in  a  chronically-inflamed 
patch  or  segment  of  the  urethra,  which  commonly  cease  on  the  removal 
of  the  exciting  cause  or  as  a  result  of  proper  treatment.  It  is  these 
relapsing  suppurations  which  laymen  often  speak  of  so  slightingly  when 
they  say  they  would  rather  have  an  attack  of  gonorrhoea  than  a  bad 
cold.  They  are  usually  promptly  responsive  to  treatment,  and  in  con- 
sequence of  the  rapidity  of  cure  in  such  cases  certain  methods  of  treat- 
ment, as  injections  of  no  particular  energy  or  value,  come  to  have  a 


THE  TWO-GLASS  TEST.  45 

great  reputation.  In  most  of  these  cases  an  actual  cure  is  not  produced. 
The  exacerbation  of  the  chronic  inflammation  is  for  a  time  stayed  and 
the  pus-production  ceases,  but  the  latent  condition  yet  remains. 

Examination  of  the  Secretion. — Much  information  as  to  the  course 
of  acute  anterior  urethritis  may  be  gained  from  a  systematic  microscop- 
ical study  of  the  secretion.     (See  Chapter  II.,  page  26,  et  seq.) 

Examination  of  the  Urine. — Much  light  is  also  thrown  on  the 
progress  of  a  case  of  acute  anterior  urethritis  by  the  examination  of 
the  urine.  In  the  prodromal  stage  the  urine  is  at  first  clear,  but  con- 
tains little  rice-like  or  suet-like  masses,  which  may  look  like  little  balls 
or  flakes  or  even  threads.  Then,  perhaps  for  a  few  hours  or  for  a  day, 
there  may  be  a  further  admixture  of  mucus  in  small  quantity.  Usually 
a  marked  change  then  ensues.  The  urine  becomes  quite  opaque,  and 
looks  very  much  as  if  Indian  meal  had  been  mixed  with  it.  This 
opacity  increases,  and  becomes  quite  intense  in  the  acme  of  the  infec- 
tion, in  the  second  and  third  weeks  and  even  later.  If  it  is  then  passed 
and  allowed  to  stand  for  several  hours,  the  pus  will  settle  to  the  bottom 
in  a  broad,  quite  firm,  seemingly  homogeneous  yellowish-white,  even 
greenish,  layer,  perhaps  an  inch  or  more  thick.  In  cases  of  hemorrhage 
a  thin  red  layer  of  blood  rests  on  the  pus-layer.  Over  this  pus-layer 
will  be  seen  a  grayish,  nebulous,  spider-web-looking,  very  easily  mov- 
able layer  of  mucus,  which  at  first  will  not  be  as  thick  as  the  underlying 
pus-layer.  As  the  case  improves  the  quantity  of  pus  becomes  grad- 
ually less  and  the  amount  of  mucus  is  increased.  As  a  result  the  urine 
is  less  opaque.  Then  as  the  case  progresses  both  pus  and  mucus  grad- 
ually disappear  and  epithelial  cells  present  themselves.  Toward  the 
end  no  pus  is  secreted,  but  a  slightly  increased  quantity  of  mucus  and 
epithelium  are  still  present.  The  conditions  being  favorable,  the  excess 
of  mucus  ceases,  the  urethra  is  healed,  and  the  patient  may  be  pro- 
nounced well.  (The  reader  is  referred  to  section  on  Gonorrhceal  Threads, 
see  page  33,  et  seq.) 

The  Two-glass  Test. — It  is  always  very  important  to  know  accurately 
how  deeply  in  the  urethra  the  infection  has  spread.  In  acute  gonorrhoea 
the  urine  may  be  examined  by  what  is  called  Thompson's  or  the  two-glass 
test.  If  the  morbid  process  is  still  confined  to  the  anterior  urethra  and  the 
purulent  secretion  is  quite  copious,  and  the  urine  is  voided  into  two  glass 
cylinders  or  beakers,  it  will  be  seen  that  the  jet  passed  into  the  first  vessel 
is  turbid,  while  that  in  the  second  is  transparent  and  clear.  It  is  then 
evident  that  the  morbid  process  is  still  localized  in  the  anterior  urethra. 
If  the  infection  has  reached  the  posterior  urethra  and  the  secretion  is 
still  quite  copious,  and  the  patient  passes  his  urine  into  two  vessels,  the 
urine  in  the  first  will  be  opaque,  and  so  will  that  in  the  second  vessel 
be.     Up  to  this  stage,  therefore,  the  two-glass  test  is  valuable  in  cases 


46  ACUTE  ANTERIOR   GONORRHOEA. 

of  gonorrhoea  of  the  totality  of  the  urethra.  In  other  words,  just  as 
long  as  the  secretion  is  quite  copious  this  two-glass  test  will  yield  accu- 
rate information ;  but  when  the  morbid  products  become  much  less  in 
quantity,  less  fluid  in  consistency,  and  more  inspissated,  then  they  are 
usually  washed  out  with  the  first  flow  of  urine,  which  flushes  and  cleans 
out  both  the  anterior  and  posterior  urethrse.  It  follows,  therefore,  that 
in  all  cases  of  declining  gonorrhoea  with  scanty  secretion,  and  in  cases 
of  chronic  gonorrhoea,  the  two-glass  test  will  be  found  wanting,  and 
will  give  no  information  as  to  whether  the  morbid  process  is  confined 
to  the  anterior  or  posterior  urethra,  or  at  best  misleading  information. 
It  is  evident  that  under  these  circumstances  a  knowledge  of  the  condi- 
tion of  the  posterior  urethra  can  only  be  obtained  by  thoroughly  cleans- 
ing the  anterior  urethra,  and  then  allowing  the  patient  to  pass  his  urine 
into  one  or  two  glasses  if  a  knowledge  of  the  condition  of  the  bladder  is 
essential.  It  is  very  important  that  this  cleansing  process  should  be 
thoroughly  done,  and  that  the  urethra  should  not  be  irritated  or 
damaged  in  any  degree  in  the  operation. 

Lavage  of  the  Anterior  Urethra. — The  most  efficient  means  of 
ascertaining  the  condition  of  the  posterior  urethra  and  bladder  is 
by  the  preliminary  washing  out  or  lavage  of  the  anterior  urethra. 
The  simplest  method  is  to  pass  down  to  the  anterior  layer  of  the 
triangular  ligament,  the  patient  being  in  a  standing  position,  a  soft- 
rubber  velvet-eye  catheter  lightly  smeared  with  glycerin,  of  No. 
10  or  12  French  scale,  or  a  reflux  catheter,  and  then,  by  means  of 
the  hand-syringe,  to  inject  five  to  ten  ounces  of  quite  warm  borax, 
boracic-acid,  or  saline  solution.  The  fluid  should  be  thrown  in  slowly, 
and  collected  as  it  runs  out  of  the  meatus.  It  may  be  well  for  a  few 
seconds  to  compress  the  meatus,  and  thus  to  cause  the  stream  to  exert 
greater  force  upon  the  urethral  walls.  When  the  water  flows  from  the 
meatus  clear  and  without  admixture  it  is  fair  to  assume,  if  proper  care 
and  technic  have  been  used,  that  the  anterior  urethra  is  cleansed. 
The  patient  may  then  pass  his  urine  into  one  or  two  glass  cylinders  or 
beakers.  If  the  quantity  of  urine  in  the  bladder  is  yet  quite  small,  it 
is  very  probable  that  the  prostatic  urethra  has  not  yet  become  part  of 
the  bladder,  and  that  its  secretion  has  not  been  regurgitated  into  or 
mixed  with  the  vesical  contents.  Consequently,  the  first  jet  of  urine 
will  carry  away  all  secretion  from  the  prostatic  urethra.  The  second 
stream,  coming  directly  from  the  bladder,  will  give  information  as  to 
its  condition,  and  will  determine  whether  the  infection  has  invaded  that 
viscus. 

Now,  in  the  event  of  the  patient  having  much  urine  in  his  bladder, 
it  is  safe  to  assume  that  the  prostatic  urethra  has  been  merged  into  that 
viscus.  and  that  its  secretion  is  mixed  with  its  contents.     As  a  result  of 


INVASION  OF  THE   WHOLE   URETHRA.  47 

this  condition  it  will  be  necessary  to  study  the  secretion  with  the  micro- 
scope after  it  has  settled,  and  to  determine  whether  the  tissue-elements 
have  come  from  the  posterior  urethra  alone  or  also  from  the  bladder. 
It  is  always  a  good  rule,  therefore,  to  use  lavage  of  the  anterior  urethra 
with  a  view  to  determine  the  condition  of  the  posterior  urethra. 
When  the  patient  has  only  three  or  four  ounces  of  urine  in  the  blad- 
der the  internal  sphincter  usually  remains  competent  and  the  prostatic 
urethra  and  bladder  do  not  then  form  one  cavity.  It  is  very  probable, 
when  the  morbid  process  in  the  posterior  urethra  is  active  and  the 
secretion  is  thin  and  copious,  that  it  tends  to  flow  toward  the  bladder, 
since  the  internal  sphincter  is  weaker  than  its  external  fellow.  In  this 
case  the  intermingling  of  the  fluids  occurs  quite  early.  If,  however,  the 
secretion  is  thick  and  viscid  and  small  in  quantity,  it  will  remain  in  the 
prostatic  urethra  until  it  is  carried  away  with  the  first  jet  of  urine,  or  it 
may  become  mixed  with  the  urine  in  the  fusion  of  the  prostatic  urethra 
with  the  bladder. 

The  secretion  washed  from  the  anterior  urethra  should  be  allowed  to 
settle,  and  then  should  be  examined  microscopically  for  gonococci  and 
tissue-elements.  The  urine  in  the  first  glass  should  be  similarly  treated. 
If  two  glasses  have  been  used,  the  second  urine  may  also  be  examined. 
If  the  bladder  has  been  involved  (and  in  most  of  the  recent  and  even 
quite  advanced  cases  the  inflammation  will  have  extended  only  to  the 
portion  near  the  neck  and  base),  there  will  be  found  more  or  less  pus 
and  flat  epithelium  due  to  catarrhal  desquamation — a  microscopical 
picture  in  striking  contrast  with  that  presented  by  the  secretion  of  the 
posterior  urethra.  By  these  means,  therefore,  we  determine  whether 
the  gonorrhceal  process  has  stopped  at  the  bulb  of  the  urethra  or 
whether  it  has  invaded  the  posterior  urethra,  and  still  further  involved 
a  small  or  a  large  portion  of  the  bladder. 

Invasion  of  the  Whole  Urethra. — The  opinion  heretofore  enter- 
tained, that  gonorrhoea,  as  a  rule,  limits  itself  to  the  anterior  urethra, 
localizing  itself  chiefly  at  the  bulbous  portion,  is  wholly  incorrect,  since 
the  reverse  is  true — namely,  that,  as  a  rule,  in  between  80  and  90  per 
cent,  of  cases  the  infection  spreads  through  the  entire  length  of  the  ure- 
thra, and  only  exceptionally  in  a  minimum  of  cases  is  it  limited  to  the 
anterior  urethra.  The  contention,  therefore,  that  posterior  urethritis  is 
a  complication  of  anterior  urethritis  is  false. 

Diagnosis. — Commonly,  the  diagnosis  of  acute  anterior  gonorrhoea 
or  urethritis  is  readily  made  by  the  physician.  Some  cases  of  balanitis, 
in  which  the  prepuce  is  rather  tight,  resemble  gonorrhoea,  for  the  reason 
that  besides  the  discharge  the  meatus  may  be  red  and  swollen,  and  per- 
haps there  is  slight  uneasiness  in  urination.  Retraction  of  the  foreskin 
and  cleansing  of  the  parts  will  permit  a  thorough  examination,  and  then 


48  ACUTE  ANTERIOR  AND  POSTERIOR   GONORRHOEA. 

the  diagnosis  can  be  readily  made.  In  those  cases  of  balanitis  in  which 
the  preputial  orifice  is  very  small,  even  of  pinhole  size,  more  difficulty 
may  be  experienced.  By  means  of  intrapreputial  injections  the  dis- 
charge may  be  removed  ;  the  parts  then  being  dried,  slight  pressure  upon 
the  urethra  from  behind  forward  will  reveal  the  presence  or  absence  of 
pus  in  the  canal.  By  means  of  the  microscope  we  can  find  gonococci  in 
the  pus  of  gonorrhoea,  but  it  is  not  found  in  that  of  balanitis. 

When  the  initial  lesion  of  syphilis  is  developed  on  or  within  the  lips 
of  the  meatus  a  slight  mucous  discharge  is  present,  and  doubt  as  to  its 
nature  may  exist  up  to  the  period  when  the  diagnosis  of  chancre  is  made. 
The  initial  lesion  may  occur  at  one  or  more  inches  down  the  canal,  and 
give  rise  to  a  discharge  which  is  usually  seropurulent  and  scanty.  Such 
patients  complain  of  a  localized  uneasiness  and  impediment  to  urina- 
tion, and  examination  reveals  a  circumscribed  thickening  of  the  corpus 
spongiosum.  In  these  cases  the  endoscope  and  the  microscope  afford 
much  aid. 

Gummatous  infiltration  occurs  at  any  part  of  the  pendulous  urethra, 
and  a  scanty  seropurulent  discharge  accompanies  its  development.  The 
absence  of  inflammatory  symptoms,  the  localization  of  the  lesion,  and 
the  history  of  the  patient  are  usually  sufficient  for  a  correct,  if  perhaps 
rather  delayed,  diagnosis. 

The  mucous  fluid  which  exudes  from  the  meatus  when  the  seat  of 
herpes  progenitalis  and  the  presence  of  vesicles  establish  the  case  as  not 
one  of  gonorrhoea. 

The  pus  of  chancroids  of  the  meatus  is  of  a  rusty-brown  color,  dif- 
fering markedly  from  that  of  gonorrhoea.  The  points  in  the  diagnosis 
of  posterior  urethritis  have  necessarily  been  given  in  the  description  of 
that  condition. 

ACUTE  POSTERIOR  GONORRHOEA,  OR  URETHRITIS. 

When  the  disease  reaches  the  bulb  of  the  urethra  that  structure 
becomes  a  profusely  suppurating  pouch,  and  from  it  in  the  majority 
of  cases  the  morbid  process,  by  cell-to-cell  invasion,  attacks  the  mem- 
branous and  prostatic  urethra?. 

Symptoms. — In  many  cases  the  onset  of  posterior  urethritis  is  unat- 
tended by  any  marked  symptoms,  and  it  is  largely  by  reason  of  this 
absence  of  symptoms  pointing  to  the  deep  extension  of  the  trouble  that 
the  opinion  was  held  that  the  posterior  urethra  is  invaded  in  only  a 
minority  of  cases. 

It  has  been  customary  to  speak  of  a  deep  burning  pain  between  the 
testes  and  in  the  perineum  as  symptomatic  of  involvement  of  the  bulb- 
ous urethra — a  contention  which  is  quite  correct.     But  it  is  equally  cer- 


ACUTE  POSTERIOR   GONORRHOEA.  49 

tain  that  this  symptom  occurs  when  the  infective  process  has  invaded 
the  urethra  beyond  the  triangular  ligament.  Its  import  has,  therefore, 
frequently  been  misconstrued.  Acute  posterior  urethritis,  moreover, 
may  exist  and  gradually  decline  in  the  manner  and  with  the  same  symp- 
tomatology that  we  have  seen  the  infection  of  the  anterior  urethra  sub- 
side. In  such  cases  there  has  been  no  suspicion  of  the  invasion  of  the 
canal  beyond  the  bulb,  and  in  all  probability  the  two-glass  test  and 
lavage  of  the  anterior  urethra,  followed  by  the  one-  or  two-glass  test, 
have  not  been  resorted  to.  Thus  it  is  that  many  instances  of  involve- 
ment of  the  posterior  urethra  have  been  unrecognized. 

If  cases  of  acute  gonorrhoea  are  carefully  watched  as  to  their  symp- 
tomatology and  the  urine  is  properly  examined,  it  will  be  found  that  in 
a  goodly  proportion  the  only  symptoms  of  posterior  urethritis  will  be  a 
slight  burning  sensation  deep  in  the  canal,  particularly  after  urinating, 
and  a  very  slight  increase  in  the  number  of  urinations.  In  many  cases 
these  symptoms  will  only  come  to  light  as  a  result  of  the  care  and  acu- 
men of  the  physician,  since  many  patients  say  nothing  about  them  or 
fail  to  take  much  notice  of  them. 

Then  there  are  other  patients  who,  when  the  discharge  is  profuse, 
will  complain  of  the  deep-seated  burning  pain  and  of  an  increased  desire 
to  make  water.  Many  of  these  cases  are  able  to  go  about  and  to  attend  to 
their  duties  during  the  acute  and  declining  stages  of  their  trouble,  which 
is  gonorrhoea  of  the  totality  of  the  urethra. 

But  the  symptoms  most  strikingly  indicative  of  invasion  of  the  pos- 
terior urethra  are  a  diminution  in  the  amount  of  the  suppuration  or  its 
entire  cessation  (even  when  it  is  profuse  and  also  when  it  is  on  the 
decline),  and  a  decidedly  increased  desire  to  urinate.  In  some  cases  the 
cessation  of  the  discharge  so  pleases  the  patient  that  he  gives  himself 
little  concern  about  the  increased  frequency  of  urination.  In  these  cases 
by  the  two-glass  test  the  first  and  second  specimens  of  urine  will  be 
found  to  be  opaque  and  to  contain  pus  and  tissue-elements.  In  some 
cases  the  second  specimen  is  more  cloudy  than  the  first.  If  no  compli- 
cations develop  in  such  cases,  the  trouble  in  the  posterior  urethra  may 
be  more  or  less  severe  for  a  time ;  then  in  most  instances  the  discharge 
again  appears,  either  copious  or  rather  scanty,  at  the  meatus  ;  the  patient 
feels  much  relieved,  and  the  case  then  behaves  like  one  of  anterior 
urethritis  on  the  decline. 

In  many  cases  in  which  a  supposed  anterior  urethritis  is  declining  in 
a  satisfactory  manner  the  patient  will  present  himself  and  complain  of 
a  frequent  and  intense  desire  to  urinate,  together  with  pain  deep  down 
in  the  perineum  at  the  end  of  micturition.  By  questioning  the  patient 
the  mode  of  onset  of  his  trouble  will  be  made  clear.  He  usually  begins 
by  urinating  in  a  normal  manner ;  but  at  the  end  of  the  act  he  experi- 

4 


50  ACUTE  POSTERIOR   GONORRHCEA. 

ences  a  dull  pain  and  weight  in  the  perineum  or  a  short,  sharp  spasm. 
This  leads  him  to  think  that  he  has  not  evacuated  the  bladder,  and  he 
then  strains,  but  expels  no  urine,  or  at  most  only  a  few  drops,  the  pas- 
sage of  which  causes  still  more  deeply-seated  pain.  Thus  ushered  in, 
the  tenesmus  begins  with  varying  degrees  of  severity.  Examination  of 
the  urine  shows  cloudiness  in  both  beakers  when  the  suppuration  is  pro- 
fuse, as  it  usually  is  in  such  cases.  This  desire  to  urinate  may  be  very 
frequent  and  imperative,  or  the  symptoms  may  be  less  pronounced.  In 
some  cases  a  patient  may  go  about,  while  in  others  he  is  forced  to  go  to 
bed.  In  severe  cases  a  further  symptom  is  added  to  the  patient's  dis- 
comfort, and  this  is  a  more  or  less  profuse  hsematuria.  In  most  cases 
the  blood  follows  the  urine,  but  in  some  it  appears  before  it  is  all  voided. 
There  may  be  but  a  few  drops  or  the  quantity  may  be  very  profuse.  In 
some  of  these  cases  of  hsematuria  in  posterior  urethritis  a  small  worm- 
like mass  of  coagulated  blood  may  be  passed  in  the  first  jet  of  urine. 
This  coagulation  is  formed  in  the  intervals  of  urination  by  the  escape  of 
blood  from  the  inflamed  prostatic  urethra.  At  the  end  of  micturition 
the  prostate  and  bladder  sphincters  contract  and  squeeze  the  inflamed 
and  eroded  lining  membrane,  thus  forcing  the  blood  from  it,  as  we  may 
by  squeezing  force  water  from  a  sponge. 

Strange  as  it  may  seem,  even  in  very  severe  and  acute  cases  there  is 
no  systemic  reaction,  there  is  no  fever,  and  there  is,  as  a  rule,  no  increase 
in  the  frequency  of  the  pulse. 

There  are,  therefore,  four  well-marked  symptoms  and  conditions  of 
posterior  urethritis,  as  follows  :  frequent  and  intense  desire  to  urinate ; 
pain  in  glans  penis  and  perineum  at  the  end  of  urination ;  post-mic- 
turitional  hsematuria  (sometimes  absent)  ;  absence  of  systemic  symptoms. 
In  addition  to  the  foregoing  classical  symptoms  there  are  two  others — 
namely,  complete  retention  and  incontinence  of  urine.  Temporary 
retention  may  occur  in  the  less  severe  order  of  cases,  due  to  spasm  of 
the  compressor  urethrse  muscle,  and  may  pass  away  without  the  surgeon 
having  to  resort  to  the  catheter.  Complete  retention,  due  to  the  same 
cause,  may  occur  in  severe  cases  in  which  there  is  urethral  stricture, 
hypertrophy,  or  abscess  of  the  prostate.  In  these  cases  prompt  surgical 
relief  is  sometimes  imperative. 

By  the  term  "  relative  incontinence "  is  understood  a  relaxed  or 
insufficient  condition  of  the  compressor  urethrse  muscle,  which  fails, 
even  when  will-power  is  exercised,  to  keep  back  the  urinary  stream. 
This  condition  is  observed  in  the  less  severe  order  of  cases.  A  sudden 
impulse  to  urinate  overtakes  the  patient,  the  bladder  contracts,  and  some 
urine  is  expelled,  perhaps  in  the  patient's  pantaloons.  Hearing  a  stream 
of  water  flowing  from  a  faucet  or  a  hydrant  or  from  a  watering-cart,  and 
washing  the  hands,  sometimes  cause  in  these  patients  vesical  contraction 


ACUTE  POSTERIOR   GONORRHOEA.  51 

and  the  escape  of  urine,  the  compressor  urethras  being  enfeebled  and 
offering  little  or  no  resistance. 

In  many  acute  cases  we  also  observe  such  symptoms  as  painful  erec- 
tions and  pollutions  which  may  be  more  or  less  bloody.  Pollutions  are 
very  significant  of  involvement  of  the  posterior  urethra,  since  they  are 
due  to  the  irritation  of  the  inflammatory  process  in  the  caput  gallinaginis. 
Chordee  is  not  observed,  unless  the  inflammation  still  remains  in  the 
acute  stage  in  the  anterior  urethra. 

In  the  general  run  of  cases  the  increased  desire  to  urinate  only  causes 
discomfort  and  not  much  pain.  Such  patients  generally  go  about  and 
rest  when  they  can.  In  other  cases  the  patients'  sufferings  may  be  said 
to  be  quite  severe.  Then,  again,  we  sometimes  see  patients  thus  afflicted 
who  become  objects  of  the  most  profound  sympathy.  While  in  some 
patients  the  desire  to  urinate  may  occur  every  hour  or  so,  in  others  it 
occurs  every  half  hour  or  less.  Then  in  very  bad  cases  the  imperious 
desire  comes  every  few  minutes,  and  in  yet  worse  cases  there  is  no  inter- 
val :  the  patient  sits  over  the  chamber  the  whole  time,  groaning  and 
crying  out  with  pain  and  drenched  in  a  cold  sweat,  passing  a  few  drops 
of  bloody  urine  at  a  time.  The  pain  is  usually  of  a  dull  character,  and 
is  felt  at  the  end  of  the  act  of  urination.  Some  patients  complain  of  pain 
at  the  end  of  the  penis  before  urination,  as  they  do  with  stone  in  the 
bladder.  This  pain  and  tenesmus  in  severe  cases  radiates  to  the  blad- 
der, anus,  lumbar  region,  spermatic  cord,  and  the  hypogastrium.  Some- 
times these  patients  also  suffer  from  cramps  in  the  legs.  In  many  cases 
nocturnal  exacerbations  are  observed.  In  these  very  bad  cases  of  acute 
posterior  urethritis  the  urine  in  the  second  glass  is  more  cloudy  than 
that  in  the  first.  These  patients  seem  instinctively  to  know  that  they 
suffer  less  when  they  pass  considerable  urine ;  hence  they  drink  large 
quantities  of  water  in  order  to  dilute  the  urine  and  to  render  it  less 
irritating. 

When  the  hemorrhage  is  very  severe  it  escapes  in  the  intervals  of 
urination  from  the  posterior  urethra  into  the  bladder,  and  then  the  first, 
and  particularly  the  second,  glass  will  be  found  to  contain  blood  as  well 
as  pus.  In  such  cases  there  is  usually  the  same  terminal  flow  of  blood 
after  urination  as  has  already  been  described. 

When  posterior  urethritis  complicates  the  condition  incident  to  hyper- 
trophy of  the  prostate,  or  when  middle-aged  or  old  men,  having  stricture 
of  the  urethra,  are  attacked  with  posterior  urethritis,  their  condition  is 
very  often  alarming  and  even  critical.  In  such  cases  the  symptoms  are 
very  severe  and  the  sufferings  of  the  patients  very  intense.  This  com- 
bination of  acute  and  chronic  disorder  is  the  more  dangerous,  as  it  may 
lead  to  rapidly-ascending  gonorrhoea  and  an  invasion  of  the  ureters  and 
the  kidneys. 


52  ACUTE  POSTERIOR   GONORRHOEA. 

Albuminuria  is  a  symptom  peculiar  to  severe  cases  of  posterior  ure- 
thritis. It  is  severe  in  proportion  to  the  intensity  of  the  tenesmus,  and 
is  said  to  be  caused  by  the  spasmodic  contraction  of  the  orifices  of  the 
ureters  by  the  detrusor  muscles  of  the  bladder,  which  dams  back  the 
urine  and  leads  to  the  escape  of  albumin  from  the  glomeruli  into  the 
renal  tubules. 

It  will  be  seen  that  in  acute  inflammation  of  the  posterior  urethra 
the  symptoms  may  be  slight  and  insignificant,  or  they  may  be  severe, 
and  even  violent  and  atrocious. 

Duration. — The  duration  of  an  attack  of  posterior  urethritis  is  very 
uncertain.  In  the  milder  forms  it  may  last  weeks  and  months,  accord- 
ing to  the  care  taken  and  the  treatment  advised.  In  moderately  severe 
cases  one  or  more  weeks,  even  as  many  as  six,  may  elapse  before  a  con- 
dition of  comfort  is  established,  even  when  the  treatment  is  correct  and 
the  care  of  the  patient  perfect.  In  the  most  severe  cases  the  duration 
is  indefinite.  Usually  such  a  violent  attack  lasts  two  or  more  weeks, 
and  then  amelioration  occurs  and  the  disease  becomes  less  severe  and 
violent. 

Declining  Stage. — The  first  symptoms  pointing  to  improvement  are 
the  less  urgent  desire  to  make  water  and  the  greater  length  of  the  inter- 
vals of  urination.  Then  the  local  and  radiating  pains  become  less,  and 
the  patient  becomes  more  comfortable  and  hopeful.  The  progress  toward 
recovery  in  very  severe  cases  is  usually  slow,  and  may  be  interrupted  by 
relapses,  which  are  often  brought  on  by  indiscretions  of  the  patient  in 
the  matter  of  alcoholic  excesses,  sexual  imprudences,  and  bodily  strains. 
In  many  cases  the  disease  ceases  to  give  the  patient  concern  and  settles 
down  into  a  chronic  condition,  in  which  there  may  be  no  subjective 
symptoms  whatever.  In  these  cases  the  discharge  is  small  in  quantity 
and  viscid  in  consistency,  and  the  two-glass  test  fails  to  localize  the 
inflammatory  process.  Resort  to  lavage  of  the  anterior  urethra,  how- 
ever, will  show  that  the  posterior  urethra  is  the  seat  of  chronic  inflam- 
mation. 

Nature  of  the  Secretion. — In  very  acute  cases  of  posterior  urethritis 
the  secretion  is  purulent  and  profuse,  like  that  of  anterior  urethritis,  and 
in  it  the  gonococcus  can  usually  be  readily  discovered.  As  the  process 
grows  older  the  pus  becomes  mixed  with  epithelial  cells  and  is  seen  in 
the  form  of  threads. 

It  is  very  difficult  and  often  impossible  to  find  the  gonococcus  by 
means  of  the  microscope  late  in  the  course  of  posterior  urethritis. 

Invasion  of  the  posterior  urethra  menaces  the  following  parts  :  the 
verumontanum,  the  ejaculatory  ducts,  the  ducts  of  the  seminal  vesicles, 
the  prostatic  ducts,  the  epididymes  and  testes,  the  seminal  vesicles,  and 
the  bladder.     Posterior  urethritis,  therefore,  may  be  the  starting-point 


URETHRITIS  IN  YOUNG  BOYS.  53 

of  various  complications,  all  of  which  are  painful  and  distressing,  and 
some  of  them  are  more  or  less  dangerous  in  their  results. 

Diagnosis. — The  diagnosis  of  acute  posterior  urethritis  is  made  by  a 
consideration  of  the  acute  attack  in  the  anterior  urethra  and  the  typical 
symptoms  of  deeper  invasion. 

Examination  of  the  urine  after  lavage  of  the  anterior  urethra  will 
establish  the  diagnosis  beyond  doubt. 

Prognosis. — In  general,  the  prognosis  of  gonorrhoea  is  good,  and  a 
cure  may  be  promised  in  from  three  to  six  or  eight  weeks,  if  proper  care 
and  treatment  are  used.  But  it  is  well  to  remember  that  in  some  cases 
gonorrhoeal  rheumatism,  epididymitis,  urethrocystitis,  and  other  compli- 
cations may  occur  even  when  a  carefully  directed  treatment  is  being  fol- 
lowed. It  may  be  stated,  however,  without  fear  of  contradiction,  that 
owing  to  improved  methods  of  treatment  the  prognosis  in  gonorrhoea 
will  grow  progressively  better  in  the  future.  The  disease  is  commonly 
very  obstinate  when  acquired  before  puberty,  particularly  in  scrofulous 
and  tuberculous  subjects.  In  plethoric  persons,  in  high  livers,  and  those 
addicted  to  drink,  in  rheumatic  and  gouty  subjects,  gonorrhoea  is  fre- 
quently very  persistent.  In  those  who  are  overworked,  the  subjects  of 
mental  worry,  and  those  of  neuropathic  tendency  the  disease  is  often 
very  tedious.  Even  in  healthy  subjects,  in  many  cases,  the  inflamma- 
tory process  is  very  rebellious  and  shows  a  tendency  to  become  localized 
in  some  part  of  the  urethra,  and  there  to  tax  the  bearer's  patience  and 
the  surgeon's  skill. 

Urethritis  in  Young  Boys. 

Catarrhal  Urethritis. — There  is  a  simple  non-specific  (certainly  as 
to  its  origin)  inflammation  of  the  meatus  and  the  anterior  portion  of  the 
urethra  in  young  boys.  I  have  seen  cases  in  which  a  mild  urethritis  of 
the  distal  part  of  the  penis  originated  in  balanitis  resulting  from  great 
uncleanliness.  In  like  manner  the  hypersemia  caused  by  pediculosis, 
scabies,  and  eczema  of  the  penis  and  gians  may  cause  a  mild  form  of 
purulent  urethritis  in  children,  as  it  does  in  the  adult.  In  the  act  of 
crawling  children  may  get  filth  on  these  organs,  and  from  this  infection 
may  occur.  I  have  several  times  seen  in  boys  from  ten  to  thirteen  years 
old  well-marked  subacute  urethritis  concomitant  with  balanitis  which 
originated  in  efforts  to  retract  the  prepuce  for  the  first  time  and  to  break 
up  adhesions.  In  these  cases  dirt,  retained  smegma,  and  urine  undoubt- 
edly played  a  prominent  causative  part. 

The  symptoms  of  mild  urethritis  in  young  male  children  are  heat, 
swelling,  pain  on  urination,  and  a  scanty  purulent  discharge. 

The  course  of  this  disease  is  tolerably  mild  and  its  duration  short, 
provided  the  exciting  causes  are  removed. 


54  URETHRITIS. 

Treatment. — Catarrhal  urethritis  will  promptly  cease  by  the  exercise 
of  cleanliness  and  the  use  of  mild  lead  injections. 

Gonorrhoeal  urethritis  in  infants  and  young  boys  is  not  infrequently 
met  with,  particularly  in  the  lower  classes  of  society  living  in  localities 
where  children  are  closely  herded  together  with  adults.  The  disease  is 
found  in  an  endemic,  quasi-epidemic,  and  sporadic  form. 

Little  is  known  as  to  the  very  early  stages  of  this  infection,  and 
there  are  no  reliable  facts  as  to  the  period  of  incubation. 

The  symptoms  are  similar  to  those  of  acute  gonorrhoea  in  the  male. 
The  disease  begins  violently  in  heat,  redness,  and  swelling  of  the  penis, 
from  which  there  is  a  profuse  discharge  of  pus.  The  morbid  process 
begins  in  the  fossa  navicularis,  and  promptly  runs  down  to  the  bulb  and 
into  the  posterior  urethra.  There  is  pain  on  urination,  besides  a  constant 
burning  sensation  in  the  urethra,  and  there  may  be  painful  nocturnal 
erections.  In  the  early  stage,  by  the  two-glass  test,  the  urine  is  found 
to  be  turbid  in  the  first  cylinder  and  clear  in  the  second ;  but  in  most 
cases  the  posterior  urethra  becomes  involved,  and  then  the  urine  in  both 
cylinders  is  turbid.  With  the  invasion  of  the  posterior  urethra  the 
symptoms  resemble  those  of  the  adult  similarly  attacked.  There  is 
tenesmus,  which  may  be  very  severe  and  occur  as  often  as  every  quarter 
of  an  hour  in  bad  cases.  In  milder  cases  the  desire  to  make  water  may 
occur  every  hour  or  at  longer  intervals.  Sometimes  mild  and  even 
severe  hemorrhage  may  occur  at  the  end  of  the  act  of  urination.  This 
disease  runs  the  same  persistent  and  rebellious  course  in  the  young  that 
it  does  in  the  adult,  and  one  or  more  months  may  elapse  before  cure  is 
effected. 

Etiology. — It  is  often  difficult,  and  even  impossible,  to  ascertain  the 
cause  and  mode  of  origin  of  virulent  gonorrhoea  in  an  infant  under  two 
i  years  of  age ;  but  the  facts  presented  by  most  cases  warrant  the  opinion 
that  the  child  has  been  tampered  with  by  an  older  person  and  thus 
infected.  Since  intromission  of  the  organ  is  not  absolutely  necessary 
for  infection,  it  is  probable  that  in  some  of  these  cases  depraved  women 
suffering  from  gonorrhoea  place  the  child's  penis  in  their  vulva.  Such 
instances  have  been  known. 

The  complications  may  be  balanitis,  lymphangitis,  epididymitis, 
orchitis,  and  vaginalitis.  In  some  cases  chronic  posterior  urethritis  is  a 
result. 

The  virulent  form  of  urethritis  in  the  young  may  lead  to  stricture  of 
the  urethra.  It  is  very  probable  that  to  virulent  urethritis  occurring  in 
early  life  may  be  attributed  many  of  the  cases  of  stricture  in  boys  and 
young  men  in  whom  a  history  of  recent  gonorrhoea  cannot  be  obtained. 

Treatment. — The  treatment  of  virulent  urethritis  of  male  infants 
and  young  boys  should  be  that  laid  down  for  adults.     The  doses,  how- 


MEMBRANOUS  DESQUAMATIVE    URETHRITIS.  55 

ever,  should  be  adjusted  to  the  patient's  age,  and  the  strength  of  the 
injections  should  be  tempered  in  accord  with  the  greater  delicacy  of  the 
young  sufferer's  tissues. 

MEMBRANOUS    DESQUAMATIVE    URETHRITIS. 

Under  the  foregoing  title  a  number  of  cases  have  been  described 
in  which  patients  passed  membranous  flakes  or  cylinders  or  casts 
from  their  urethra.  In  the  cases  thus  far  reported  we  find  a  marked 
variation  in  the  character  of  the  membranes  and  in  the  subjective  and 
objective  symptoms  of  the  patient  passing  them. 

Though  a  few  cases  will  not  warrant  sharply-drawn  conclusions,  the 
opinion  may  be  ventured  that  there  are  a  croupous  urethritis  and  a  well- 
defined  epithelial  desquamative  urethritis,  the  one  being  acute,  the  other 
chronic. 

These  cases  should  be  treated  on  the  general  lines  indicated  in  the 
management  of  chronic  anterior  urethritis.     (See  page  83,  et  seq.) 


CHAPTER    IV. 

TREATMENT    OF    ACUTE   ANTERIOR   AND    POSTERIOR    GON- 
ORRHOEA,  OR  URETHRITIS. 

The  treatment  of  gonorrhoea  varies  according  to  the  stage  of  the 
disease  and  the  condition  of  the  patient.  In  the  majority  of  cases  gon- 
orrhoea is  seen  in  the  acute  stage,  with  its  well-developed  purulent  dis- 
charge and  inflammatory  symptoms.  Exceptionally  patients  present 
themselves  a  few  hours  or  a  day  or  two  after  the  onset  of  the  prodromal 
stage.  In  every  instance,  if  possible,  when  a  patient  presents  himself 
in  this  stage,  the  secretion  should  be  examined  by  means  of  the  micro- 
scope. 

The  Abortive  Treatment. 

When  on  the  first  and  perhaps  the  second  day  the  patient  complains 
of  a  little  tickling  or  burning  sensation,  and  the  mucoid  secretion,  con- 
taining little  whitish-gray  particles  resembling  suet  or  rice,  shows  noth- 
ing but  epithelial  cells  and  gonococci,  but  no  pus-cells,  then  the  patient 
being  desirous  and  urgent,  the  surgeon  should  make  an  effort  to  abort 
the  disease.  Under  these  circumstances  he  can  offer  a  reasonable  hope. 
He,  however,  should  make  it  very  clear  to  the  patient's  mind  that  the 
treatment  may  be  quite  painful,  and  that  it  may  fail.  However,  even 
when  the  reaction  following  the  treatment  is  severe  it  is  readily  calmed 
in  a  few  days.  The  method  of  procedure  is  as  follows  :  The  patient 
stands  and  urinates,  and  the  urethra  is  injected,  by  means  of  a  penis- 
syringe  or  of  a  Xo.  12  French  soft  catheter  introduced  three  and  a  half 
inches  into  the  urethra,  with  one  or  more  ounces  of  very  warm  saturated 
solution  of  boric  acid.  Then  a  meatoscope  is  introduced,  the  obturator 
withdrawn,  and  an  applicator  charged  on  its  end  with  a  tuft  of 
absorbent  cotton,  large  enough  to  spread  gently  the  urethral  lumen 
and  soaked  in  a  watery  solution  of  nitrate  of  silver,  15  grains  to  the 
ounce,  is  pushed  down  the  tube,  and  the  cotton  is  allowed  to  protrude 
just  bevond  it.  Then  the.  tube  and  the  applicator  are  very  slowly  with- 
drawn, the  surgeon  gently  rotating  them  from  side  to  side.  After  this 
operation  the  patient  should  lie  down  and  apply  graduated  cold  either 
by  means  of  an  ice-bag  or  of  ice- water  on  lint  to  the  penis.  A  cathartic 
should  be  given  and  low  diet  allowed.  The  reaction  may  be  slight, 
or  it  may  be  very  severe.  Usually  in  a  few  hours  the  discharge  be- 
comes decidedly  purulent  and  copious,  and  urination  is  attended  with 
scalding.     If  success  has  been  attained,  the  suppuration  (for  a  substitu- 


TREATMENT  OF  THE  ACUTE  STAGE.  57 

tive  inflammation  has  been  produced)  gradually  grows  less,  the  secre- 
tion becomes  thin,  watery,  and  perhaps  a  little  bloody,  and  disappears 
in  four  or  five  days.  In  some  cases  an  astringent  injection  may  be 
required  to  cause  the  mucous  membrane  to  become  healthy.  In  the 
event  of  failure  the  acute  stage  develops  with  perhaps  much  severity. 

By  this  procedure  the  gonococci  are  destroyed,  and  the  epithelial 
laver  upon  which  they  are  seated  is  so  necrosed  by  the  caustic  that  it  is 
thrown  off.  In  a  few  days  it  is  replaced,  the  engorgement  of  the  ves- 
sels and  the  oedema  of  the  tissues  subside,  and  a  healthy  condition  is 
left. 

A  less  radical  and  less  painful  procedure  consists  in  the  introduction 
to  the  extent  of  three  or  four  inches  into  the  already  cleansed  urethra 
of  a  No.  12  F.  soft-rubber  catheter  and  the  injection  of  several  anti- 
septic solutions  at  the  temperature  of  100°  F.  For  this  purpose  per- 
manganate of  potassium,  1  :  1000  or  1 :  2000,  may  be  thrown  into  the  ure- 
thral canal  twice  a  day ;  or  bichloride  of  mercury  and  water,  1  :  2000 
or  1  :  5000,  or  of  nitrate  of  silver,  1  :  3000  or  1  :  5000,  may  be  used.  In 
the  quite  early  stage  these  retrojection  fluids  may  be  used  of  much 
greater  strength  than  can  be  borne  when  the  acute  stage  is  well  devel- 
oped. By  these  means  I  have  been  able  to  abort  gonorrhoea  when  it 
was  in  the  exact  condition  already  described. 

When  the  gonococci  have  penetrated  into  the  epithelial  layer,  par- 
ticularlv  when  they  have  reached  the  region  of  the  vessels  and  have 
produced  an  exudation  of  leucocytes,  when  we  have  under  the  micro- 
scope pus-cells  and  epithelial  cells,  the  abortion  of  gonorrhoea  is  a  very 
difficult  and  very  often  indeed  an  unsuccessful  task.  In  these  conditions 
either  of  the  first-mentioned  retrojections  may  be  given.  They  should 
be  quite  copious,  twelve  ounces  or  a  pint  being  thrown  up  at  each  session 
by  the  surgeon  himself  or  his  assistant. 

Treatment  of  the  Acute  Stage. 

The  surgeon  should  carefully  examine  the  penis  of  every  man  present- 
ing himself  for  the  treatment  of  gonorrhoea.  He  thus  familiarizes  himself 
with  the  anatomical  peculiarities  of  the  organ,  and  can  thus  foresee  and 
take  measures  to  prevent  complications.  Thus  a  long  tight  prepuce  may 
lead  to  balanitis,  to  phimosis,  or  to  paraphimosis,  or  even  to  lymphitis 
and  adenitis.  These  complications  are  readily  prevented ;  but  if  they 
supervene,  the  sufferings  of  the  patient  are  much  increased  and  his  cure 
is  greatly  delayed.  Then,  again,  the  conformation  of  the  meatus  should 
be  taken  into  consideration,  with  the  view  of  ordering  for  the  patient  a 
syringe  best  adapted  to  the  parts.  Should  there  exist  a  tendency  to 
balanitis  or  if  any  warts  are  present  upon  or  around  the  glans,  attention 
must  be  paid  to  them.     In  a  case  of  very  small  meatus  an  incision  may 


58  TREATMENT  OF  ACUTE  OONORRHCEA. 

be  required  as  early  as  it  is  practicable  in  the  course  of  the  virulent 
inflammation. 

Assuming,  now,  that  we  have  to  treat  an  acute  case,  either  as  a  first 
or  a  later  infection,  the  most  important  measure  is  absolute  rest,  pref- 
erably in  the  recumbent  position,  but  the  majority  of  patients  are 
unwilling  thus  to  submit.  The  great  advantages  to  be  attained,  how- 
ever, should  be  thoroughly  explained  to  them.  Taking  cases,  therefore, 
as  we  find  them,  they  should  be  enjoined  to  walk  and  exercise  as  little  as 
possible,  to  spare  themselves  in  every  way,  to  avoid  muscular  exertion, 
to  ride  rather  than  walk,  to  sit  rather  than  stand,  and  to  lie  down  as 
often  and  as  long  as  possible.  Horseback  riding,  bicycling,  out-door 
sports,  dancing,  jumping — in  fact,  any  form  of  severe  bodily  exercise — 
are  to  be  absolutely  avoided.  In  very  bad  cases,  in  which  the  inflam- 
mation is  so  active  that  a  patient  is  forced  to  seek  the  recumbent  posi- 
tion, it  is  well  to  apply  cooling  lotions  on  lint  to  the  organ  or  to  employ 
an  India-rubber  ice-bag.  For  all  itinerant  cases  in  the  acute  stage  a 
nicely-fitting  and  comfortable  suspensory  bandage  should  be  ordered  at 
once.  Care  should  be  taken  that  the  opening  for  the  penis  is  suf- 
ficiently large,  and  that  the  urethra  is  not  in  any  degree  pressed  upon 
by  the  bandage. 

The  patient  must  be  informed  of  the  great  virulency  of  the  urethral 
pus,  and  that  contamination  of  the  eyes  with  it  may  result  in  the  loss  of 
one  or  both  of  these  organs.  Therefore  the  hands  should  be  thoroughly 
washed  immediately  after  handling  the  penis.  Too  much  stress  cannot 
be  laid  upon  this  injunction. 

Carefid  attention  to  diet  is  an  important  consideration.  It  should  be 
light  and  plain  and  in  moderate  quantity.  All  highly-seasoned  foods, 
salads,  gravies,  soups,  and  condiments  should  be  absolutely  interdicted. 
Coffee,  cocoa,  beer,  alcoholic  liquors,  ginger  ale,  and  asparagus  should 
be  avoided.  The  utmost  cleanliness  of  the  genital  parts  should  be  rec- 
ommended, using  by  preference  carbolic-acid  soap.  All  sexual  excite- 
ment must  be  sedulously  avoided,  and  the  patient  should  be  warned 
against  lascivious  thoughts  and  suggestive  pictures. 

Much  care  is  necessary  in  adapting  dressings  to  the  penis  for  the  pur- 
pose of  catching  the  discharge.  Patients  should  be  warned  not  to  place 
pieces  of  lint  or  cotton  over  the  urethral  orifice,  nor  to  use  stockings  or 
bags  at  the  bottom  of  which  a  bird's-nest-shaped  wad  of  cotton  is  placed, 
since  by  all  of  these  procedures  the  pus  is  injuriously  kept  against  the 
meatus  and  glans.  India-rubber  condoms  are  also  objectionable.  The 
most  cleanly  and  efficient  method  of  dressing  the  penis  is  as  follows  : 
A  piece  of  old  linen  or  muslin  or  two  thicknesses  of  absorbent  gauze 
about  four  inches  square,  in  the  center  of  which  is  a  small  oval  aper- 
ture, is  slipped   over  the  exposed  glans  behind  the  corona,  and  the 


TREATMENT  OF  THE  ACUTE  STAGE. 


59 


prepuce  is  then  pushed  forward.  From  its  orifice  the  linen  protrudes  and 
catches  all  of  the  secretion.  (See  Figs.  14  and  15.)  If  the  patient  has 
no  foreskin  thus  to  hold  the  bandage,  a  piece  of  linen  or  gauze,  four  by  six 
inches,  may  be  wound  around  the  whole  penis,  and  there  retained  by  means 
of  a  small  piece  of  adhesive  plaster  or  a  loosely  fitting  India-rubber  band. 


Fig.  14. 


Fig.  15. 


v  Aw  ■  ■,■■». 

ill 


Dressings  for  the  penis  in  acute  gonorrhoea. 

All  these  dressings  for  the  penis  should  after  use  be  destroyed  by  fire,  or 
at  least  thrown  down  a  water-closet.  The  surgeon  should  emphasize 
this  important  prophylactic  measure.  If  practicable,  the  penis  may  be 
suspended  by  means  of  the  under-clothes  along  the  fold  of  the  groin. 
The  utmost  care  and  delicacy  must  be  observed  in  handling  the  organ : 
squeezing  to  cause  pus  to  exude  is  very  harmful,  and  pressure  of  any 
kind  must  be  avoided. 

During  the  acuteness  of  the  attack  purgation  at  intervals  of  three 
or  four  days  is  very  essential.  For  this  purpose  two  to  four  compound 
cathartic  pills  or  ten  grains  each  of  calomel  and  supercarbonate  of  sodium 
taken  at  night  are  excellent.  Saline  cathartics  and  the  natural  cathartic 
waters  are  to  be  avoided,  since  much  of  the  sulphate  of  magnesium  passes 
oif  in  the  urine  and  irritates  the  urethra. 

Early  in  the  acute  or  inflammatory  stage  of  gonorrhoea  strong  stim- 
ulating and  astringent  injections  and  oleoresins  are  contraindicated.  The 
chief  object  of  our  therapeusis  at  this  time  is  to  render  the  urine  mode- 


60  TREATMENT  OF  ACUTE  GONORRHOEA. 

rately  alkaline,  bland,  and  as  little  irritating  as  possible.  For  this  pur- 
pose there  is  no  better  remedy  than  the  bicarbonate  of  potassium.  In 
general,  the  following  prescription  may  be  used : 

Jfy.  Potassii  bicarbonatis,  5J  ; 

Tr.  hyoscyami,  3ss  ; 

Aquse,  3vuj- — M. 

Dose  for  an  adult,  one  tablespoonful  in  a  wineglass  of  water  three  times 
a  day  an  hour  after  eating. 

Milk,  vichy  water,  and  the  various  table  waters  may  be  freely  par- 
taken of. 

Locally,  the  most  important  measure  is  the  immersion  of  the  penis 
in  very  hot  boric-acid  solution  for  fully  fifteen  minutes  three  times  a 
day,  by  which  means  the  pain  and  soreness  are  relieved  and  the  red- 
ness and  swelling  reduced.  A  small  quantity  of  laudanum  or  of  fluid 
extract  of  belladonna  may  often  be  with  benefit  added  to  the  hot  water. 
In  the  early  days  of  the  inflammatory  stage  baths  at  a  temperature  of 
96°  or  98°  F.  are  of  much  service  in  tending  to  produce  a  comfort- 
able night's  sleep.  If  possible,  the  whole  body  should  be  immersed  ;  if 
not,  the  hip-bath  may  be  used.  Immersion  of  the  penis  in  very  hot 
water  during  urination  is  often  productive  of  amelioration  of  pain. 

For  the  prevention  of  erections  and  chordee,  besides  the  observance 
of  a  rigid  hygiene,  the  patient  must  retire  early  and  sleep  on  his  side, 
and  never  on  his  back,  on  a  hair  mattress,  with  light  bed-clothes.  It  is 
always  well,  if  possible,  to  avoid  the  use  of  anodynes,  and  much  benefit 
has  been  derived,  in  my  experience,  from  the  use  of  the  following  injec- 
tion in  cases  of  persistent  nocturnal  erections  and  chordee  : 


Liq.  morphia?  Magendie, 

3ij; 

Cocain  muriat., 

gr.  vj-viij  ; 

Aquse, 

3ij.— M. 

Of  this  one  or  two  drachms  may  be  carefully  and  slowly  thrown  into 
the  urethra,  by  means  of  a  medicine-dropper,  and  there  retained  for 
fully  five  minutes,  just  before  retiring. 

For  immediate  use  any  cold  body,  such  as  a  flat-iron,  may  be  applied 
to  the  perineum  and  the  under  surface  of  the  urethra,  or  cold-water 
affusions  may  be  tried.  Owing  to  idiosyncrasy,  cold  is  not  beneficial  in 
some  cases,  while  hot-water  immersions  are  very  efficacious. 

In  those  cases  in  which  there  is  much  malaise,  nervousness,  and 
worriment,  when  hyoscyamus  fails,  laudanum  in  doses  of  two  or  three 
drops  in  a  small  quantity  of  water,  taken  three,  four,  or  five  times  a 
day,  is  productive  of  a  sense  of  comparative  comfort  during  the  day 
and  of  sleep  at  night. 


TREATMENT  OF  THE  ACUTE  STAGE.  61 

In  some  cases,  besides  the  erections  and  chordee,  there  is  consider- 
able vesical  irritation,  with  frequent  and  imperious  desire  to  urinate, 
together,  perhaps,  with  pain  in  the  perineum,  loins,  scrotum,  and 
groins,  due  to  the  onward  extension  of  the  infection.  In  such  cases 
laudanum,  as  just  advised,  may  be  used,  or  suppositories  may  be 
ordered,  as  follows  : 

I^j.  Morphia?  sulphatis,  gr.  ij  ; 

Ext.  belladonna?,  gr.  iij  ; 

Ol.  theobromse,  q.  s. 

To  make  suppositories  No.  iv. 

One  of  these  may  be  introduced  into  the  rectum  just  on  retiring,  and 
a  second  during  the  night  if  necessary.  In  many  cases  calm  sleep  may 
be  induced  by  using  the  following  combination,  which  is  not  followed 
by  unpleasant  effects  : 

1^.  Potassii  bromidi,  Bxvj  ', 

Chloral,  hydrat.,  gr.  lxxx  ; 

Liq.  morphise  Magendie,  gtt.  lxxx  ; 

Syr.  simplicis, 

Aqua?,  da  sj. — M. 

Dose,  one  teaspoonful  in  a  little  water  on  retiring,  and  it  may  be 
repeated  during  the  night  if  necessary.  In  some  cases,  owing  to  intol- 
erance, the  quantity  of  all  of  the  active  agents  may  be  suitably  increased. 
Bromide  of  potassium  alone  proves  of  much  benefit  in  the  milder  order 
of  cases. 

Antipyrine  is  very  often  soothing  and  beneficial  in  acute  gonor- 
rhoea and  in  various  forms  of  cystitis.  This  remedy  may  also  be  given 
in  combination  with  phenacetin ;  sulphonal  and  trional  may  also  be  of 
benefit. 

The  tendency  of  gonorrhcea  being  toward  disturbance  of  the  nervous 
system  and  debility,  much  care  and  attention  are  required  in  preventing 
them.  Purgation  must  not  be  pushed  to  the  extent  of  weakening  the 
patient ;  and  if  signs  of  falling  away  show  themselves,  a  rather  more 
liberal  diet  should  be  allowed  so  soon  as  admissible. 

In  the  florid  stage  of  gonorrhoea,  with  its  profuse  yellowish  and 
perhaps  bloody  discharge,  coming  from  a  very  highly  inflamed  and 
swollen  mucous  membrane,  it  becomes  a  nice  question  whether  one  can 
apply  local  medication.  As  the  case  improves  by  reason  of  the  general 
treatment  and  the  immersions  of  hot  boric  solution  we  may  then  order 
the  patient  to  keep  a  portion  of  this  fluid  for  injection  purposes.  He 
should  then  procure  a  proper  syringe  and  should  be  carefully  instructed 
how  to  use  it. 


62  TREATMENT  OF  ACUTE  GONORRHOEA. 

Care  should  be  exercised  in  selecting  a  syringe  "which  should  hold 
two  or  three  drachms,  should  work  easily,  and  its  nozzle,  which  should 
be  perfectly  smooth,  should  fit  readily  into  the  meatus.     Fig.  16  shows 

Fro.  16. 


a  particularly  useful  instrument  for  all  cases  ;  its  tube  is  of  hard  rubber 
and  its  nozzle  is  conical  in  shape  and  soft  and  compressible,  being  made 
of  soft  black  rubber. 

The  technic  of  injection  is  as  follows  :  The  patient  stands  with  his 
feet  about  three  feet  apart,  or  he  may  sit  on  the  edge  of  a  stool,  his 
weight  resting  on  the  coccyx.  With  the  forefinger  and  thumb  of  the 
left  hand  the  patient  separates  the  vertical  lips  of  the  meatus,  while  he 
steadies  the  penis  with  the  middle  finger.  The  point  of  the  syringe, 
held  in  the  right  hand,  being  in  the  meatus,  the  thumb  and  forefinger 
compress  the  lips  together  underneath  the  nozzle,  by  which  manoeuvre 
the  reflux  of  the  injection  is  prevented.  In  order  that  benefit  shall 
result  it  is  necessary  that  the  fluid  shall  reach  every  portion  of  the 
mucous  membrane  of  the  anterior  urethra,  including  the  bulb,  and  that 
the  canal  shall  be  somewhat,  but  mildly,  distended  in  the  operation. 
It  is  always  well  for  the  surgeon  to  warn  patients  to  proceed  slowly  and 
cautiously,  being  careful  to  avoid  rapid  and  forcible  distention  of  the 
canal.  It  is  a  good  rule  to  begin  with  the  slow  injection  of  about  one 
drachm  of  fluid,  and  then  to  increase  as  the  tolerance  of  the  urethra 
will  admit,  until  a  syringeful  can  be  thrown  in  the  canal  without  any 
resistance  whatever.  In  this  way  the  urethra  becomes  accustomed  to 
the  operation,  and  its  walls  can  be  well  acted  upon  by  the  medicated 
fluid. 

After  each  immersion,  therefore,  the  patient  may  throw  four  or  five 
syringefuls  of  the  hot  boric  solution  as  far  down  the  urethra  as  he  can 
without  discomfort.  In  most  cases  with  a  little  practice  he  soon  medi- 
cates the  whole  anterior  urethra.  As  a  rule,  the  treatment  alleviates  the 
patient's  sufferings  and  lessens  the  inflammation.  "With  the  onset  of 
amelioration,  which  usually  occurs  in  a  few  days,  we  can  adopt  a  more 
radical  and  local  treatment.  To  this  end  we  introduce  as  far  as  the  bulb 
the  soft  and  compressible,  bulbous-ended  soft-rubber  reflux  catheter, 
which  can  be  gently  passed,  without  discomfort  or  any  damage,  down  to 
the  bulb,  and  through  it  we  can  slowly  throw  two,  four,  or  six  ounces 


TREATMENT  OF  THE  ACUTE  STAGE.  63 

of  the  warm  boric  solution,  which  returns  and  flows  out  of  the  meatus. 
As  a  result  of  these  procedures  the  patient  becomes  much  more  comfort- 


Fig.  17. 


39 


Reflux  Catheter. 


able,  and  there  is  a  perceptible  improvement  in  the  urethral  inflamma- 
tion. When  this  subsidence  of  the  very  acute  stage  is  noted  we  may  go 
a  step  farther  with  our  local  applications.  Thus  we  may  replace  the 
boric  solution  with  warm  lead-water,  or  we  may  use  a  warm  solution  of 
permanganate  of  potassium,  not  stronger  than  1  :  4000,  or  protargol 
1  :  200.  It  is  too  early  to  speak  definitely  of  the  value  of  argonin,  largin, 
or  argentamin. 

It  cannot  be  denied  that  in  some  cases  of  gonorrhoea  early  in  the 
florid  stage  permanganate  of  potassium,  when  used  in  the  conservative 
manner  here  directed,  will  very  much  attenuate  the  inflammatory  symp- 
toms ;  but  it  cannot  be  too  clearly  understood  that  its  sphere  of  useful- 
ness is  in  the  conditions  now  indicated,  and  that  it  does  not  act  deeply 
enough  to  produce  a  cure.  The  heroic  and  indiscriminate  use  of  this 
remedy  which  is  now  so  prevalent  is  very  much  to  be  regretted. 

Under  the  mild  graduated  antiseptic  measures  here  outlined  much 
improvement  will  be  produced  as  a  rule.  If,  as  so  often  happens, 
even  when  care  and  prudence  are  exercised,  the  posterior  urethra 
becomes  attacked,  it  may  be  well  to  employ  the  ordinary  velvet-eyed 
catheter  (using  very  small  ones,  10  to  12  of  French  scale),  and  to  inject 
some  of  the  fluid  into  the  posterior  urethra.  These  measures  reduce  the 
acute  inflammation,  and  in  that  way  render  the  tissues  less  susceptible 
to  the  action  of  the  micro-organism  ;  then  as  the  treatment  is  carefully 
kept  up  the  microbes  die,  since  the  condition  of  the  tissues  is  not  favor- 
able to  their  nutrition.  When  the  acute  suppuration  begins  to  subside 
the  patient  may  be  ordered  to  use  injections  having  as  their  base  various 
astringents.  It  should  be  remembered,  however,  that  the  injections 
administered  by  the  patient  himself  only  medicate  the  anterior  ure- 
thra and  that  the  treatment  of  the  posterior  segment  is  to  be  adminis- 
tered by  the  surgeon.  Medication  of  the  anterior  urethra,  however,  is 
of  very  decided  benefit. 

The  drugs  generally  used  for  urethral  injections  are  the  sulphate, 
acetate,  sulphocarbolate,  and  chloride  of  zinc,  acetate  of  lead,  sulphate 
of  copper,  sulphate  of  alum  and  of  thalline,  muriate  of  hydrastis,  and 
the  white  fluid  extract  of  hydrastis.  As  a  broad  general  rule,  all  of  the 
above  drugs,  except  the  chloride  of  zinc  and  sulphate  of  copper,  may  be 
used  in  the  beginning  of  treatment  in  |  or  1  per  cent,  solutions  in  water. 


64  TREATMENT  OF  ACUTE  GONORRHCEA. 

The  chloride-of-zinc  solution  should  be  1  :  1000  or  1  :  500  to  begin  with, 
and  if  its  use  warrants  its  continuance  it  may  be  used  of  the  strength 
of  1  :  200  or  1  :  250.  It  is  always  well  to  proceed  cautiously  with  this 
drug.  The  sulphate-of-copper  injection  should  be  1  :  500,  and  it  may  be 
increased  to  1  :  100 ;  but  if  it  fails  to  produce  good  results  in  this  strength, 
it  is  well  to  discard  its  use.  No  reliance  can  be  placed  on  tannin.  The 
foregoing  is  a  quite  generous  armamentarium  for  injections,  and  all  of 
them  may  be  employed  carefully  in  the  beginning  of  the  declining 
stage. 

The  following  injections  may  be  used,  care  being  taken  to  dilute 
them  if  they  produce  any  uneasy  symptoms  beyond  a  feeling  of  pleasant 
warmth.  For  the  very  first  series  of  injections  a  solution  containing 
one  grain  each  of  acetate  of  lead  and  of  acetate  of  alum  to  the  ounce  of 
water  will  generally  prove  very  acceptable.     Other  injections  are — 

Jfy.  Zinci  sulphatis,  vel  acetatis,  gr.  vj  ad  viij  ; 

Liq.  Magendie,  Sij  ; 

Aquse,  q.  s.  ad  siv. — M. 

A  combination  of  sulphate  of  zinc  and  acetate  of  lead  forms  a  very 
excellent  injection,  as  follows  : 

Jfy.  Zinci  sulphat., 

Plumbi  acetat.,  ad  gr.  vj  ad  xij  ; 
Ext.  opii  aq.,  3ij  ; 

Aquae,  §vj. — M. 

Jfy.  Bismuth,  subnit.  or  zinci  carbon.,  3iij  ; 
Tr.  catechu, 

Vin.  opii,  act  3ij  ; 

Glycerinse,  sss ; 

Aquse,  ad  syj. — M.  To  be  well  shaken. 

At  this  time — namely,  the  declining  stage — it  is  well  to  leave  off  the 
use  of  the  alkaline  mixture  and  to  begin  the  use  of  the  standard  anti- 
blennorrhagics,  copaiba,  cubebs,  and  oil  of  santal,  in  a  sparing  manner. 
In  private  practice  these  remedies  should,  as  a  general  rule,  be 
administered  in  capsule  form.  In  default  of  American  productions 
(which  is  very  singular,  when  we  consider  how  far  we  are  advanced 
in  the  art  of  pharmacy)  we  resort  to  French  capsules.  Raquin's  cap- 
sules of  copaiba  are  of  especial  worth,  and. three  of  them  may  be  given 
as  a  dose,  repeated  three  times  a  day.  The  cubebs  and  copaiba  capsules 
of  Mathey-Caylus  are  also  efficient,  and  should  be  given  in  the  same 


TREATMENT  OF  THE  DECLINING  STAGE.  65 

quantity  as  the  Raquin  capsules.  We  have  so  many  excellent  capsules 
of  pure  oil  of  yellow  santal  made  in  this  country  that  we  need  not  go 
abroad  for  foreign  productions.  In  general  terms,  thirty  to  sixty  drops 
of  oil  of  santal,  divided  into  three  doses,  should  be  given  daily,  so  that, 
when  the  capsules  contain  five  drops,  six  to  twelve  may  be  given,  or 
when  they  contain  ten  drops,  six  will  usually  be  sufficient.  The  close 
can  be  pushed  slightly  higher;  but  the  surgeon  should  always  look  out 
for  the  gastric  effects  of  the  oil,  and  should  discontinue  its  use  if  severe 
lumbar  pain,  supposed  to  be  due  to  renal  congestion,  is  complained  of. 
Salol  some  years  ago  was  looked  upon  as  the  coming  antiblennorrhagic, 
but  the  general  opinion  of  those  who  use  it  is  that  it  is  only  feebly  active 
or  really  inert. 

The  capsules  already  mentioned,  being  somewhat  expensive,  cannot 
be  used  in  dispensaries  and  clinics.  The  combination  known  as  Lafayette 
mixture  is  a  very  good  one,  and  is  very  largely  used  in  nearly  all  med- 
ical charities.  Should  these  remedies  cause  gastro-intestinal  symptoms 
or  produce  erythematous  rashes  their  use  should  be  stopped  immediately. 
At  the  present  time  when  we  act  upon  gonorrhoea  by  direct  local  meas- 
ures, it  is  not  necessary  to  use  the  antiblennorrhagics  in  such  large  doses 
and  for  such  long  periods  as  we  did  in  the  past. 

When  the  reparative  or  declining  stage  has  fully  set  in  the  discharge 
is  decidedly  less  copious  and  is  no  longer  of  greenish  color,  but  is  more 
viscid  and  of  a  grayish  hue.  Under  the  microscope  it  is  found  to  con- 
sist of  considerable  pus,  fewer  gonococci,  and  much  immature  epithe- 
lium. The  presence  of  these  epithelial  cells  is  a  harbinger  of  good 
omen,  for  it  indicates  that  nature  shows  a  tendency  to  repair  the  damage 
done  and  to  replace  the  natural  covering  of  the  urethra.  In  this  condi- 
tion she  needs  active  assistance,  and  at  this  time  the  surgeon  can  really 
do  valuable  work.  The  pathological  indications  which  present  them- 
selves for  relief,  are  :  First,  to  cause  the  absorption  of  the  round-cell 
submucous-tissue  exudation  and  the  restoration  of  the  tonicity  of  the 
vessels ;  and,  second,  to  produce  a  new  epithelial  covering  for  the  ure- 
thra. Experience  shows  that  the  most  reliable  and  effective  agent  for 
this  purpose  is  the  nitrate  of  silver.  This  agent  when  skilfully  used 
will  in  general  answer  all  expectations.  By  its  stimulant  action  it 
causes  the  absorption  of  the  submucous  exudate  and  constringes  the 
vessels  ;  and  by  its  astringent  action  it  acts  powerfully  and  well  on  the 
relaxed  and  catarrhal  mucous  membrane,  and  tends  to  produce  on  it  a 
new  and,  in  the  end,  stable  epithelium.  When,  therefore,  the  symp- 
toms of  the  patient  and  the  microscopical  appearances  of  the  discharge 
indicate  that  the  morbid  process  is  about  to  decline — and  this  may  be  as 
early  as  the  tenth  or  fourteenth  day,  or  as  late  as  the  twentieth  of  treat- 
ment— it  is  our  duty  to  begin  the  use  of  this  drug.    If  only  the  anterior 

5 


66 


TREATMENT  OF  ACUTE  GONORRHCEA. 


urethra  is  involved,  we  may  use  the  reflux  catheter ;  but  if  the  totality 
of  the  canal  has  been  attacked  (as  it  so  frequently  is),  the  10,  12,  or  14 
French  velvet-eyed  catheter  should  be  employed.  Assuming  that  only 
the  anterior  urethra  is  involved,  the  reflux  catheter  lubricated  with 
glycerin  or  lubrichondrin  is  gently  passed  to  the  bulb,  where  it  will 
stop.  Then,  by  means  of  a  Hayden's  irrigating  syringe  (see  Fig.  18), 
irrigation  is  slowly  made,  and  by  it  the  urethra  from  the  bulb  to  the 

Ficx.  18. 


Irrigating  syringe  and  stop-cock  (all  metal ;  4  oz.).    (Hayden.) 


meatus  is  thoroughly  medicated.     In  irrigating  both  the  posterior  and 
the  anterior  urethra  the  procedure  is  as  follows  : 

The  soft-rubber  catheter  is  passed  down  the  urethra  until  the  urine 
flows,  which  will  usually  occur  when  the  instrument  has  got  as  far  as 
seven  or  seven  and  a  half  inches  down.  The  bladder  being  empty, 
pressure  on  the  piston  then  throws  the  injection  into  the  prostatic 
urethra.  It  is  well  now  to  withdraw  the  catheter  a  little  until  its  end 
is  in  the  membranous  urethra ;  then  on  pressing  the  piston  gently 
resistance  will  be  felt  and  no  fluid  will  flow.  This  tells  the  surgeon 
that  he  is  in  the  membranous  urethra,  and  that  the  irritation  of  his 
procedure  has  caused  contraction  of  the  compressor  urethra?  muscle. 
Then  push  the  catheter  inward  about  half  an  inch  and  inject  again, 
when  the  fluid  will  pass  readily.  By  this  manoeuvre  the  eye  of  the 
catheter  is  placed  just  at  the  apex  of  the  prostate  and  at  the  very  begin- 
ning of  the  prostatic  urethra.  The  injection  is  then  slowly  thrown  in, 
and  it  passes  through  the  whole  of  the  prostatic  urethra  into  the 
bladder.  If  only  a  rather  small  injection  is  to  be  given,  about  one-half 
of  the  contents  of  the  syringe  may  be  used  posteriorly.  Then,  while 
still  pressing  the  piston,  the  surgeon  gently  draws  out  the  catheter,  and 
finds  that  as  its  eye  passes  through  the  membranous  urethra  the  flow 
stops  again,  but  is  at  once  resumed  when  the  eye  reaches  the  bulbous 
urethra,  which  is  then  irrigated  with  the  remainder  of  the  fluid.  It 
may  be  necessary  to  use  one  syringeful  for  the  posterior  urethra  and 


TREATMENT  OF  THE  DECLINING  STAGE.  67 

another  for  the  anterior.  The  sensations  of  the  patient  and  the  condi- 
tion of  the  urine  are  the  indices  for  the  continuance  of  the  treatment. 
Usually  a  feeling  of  benefit  is  produced,  and  the  patient  desires  another 
irrigation  in  a  day  or  two.  It  is  always  well  to  proceed  very  cautiously. 
If  the  treatment  is  well  borne  and  the  urine  shows  a  decline  in  the 
quantity  of  pus  and  mucus,  and  the  epithelial  cells  show  rather  more 
development,  then  one  is  safe  in  going  on.  It  is  most  important  not  to 
give  the  injections  too  frequently,  and  this  point  will  be  determined  by 
the  sensations  of  the  patient  and  the  examination  of  the  urine. 

The  first  irrigation  should  consist  of  two  to  four  ounces  of  a  warm 
solution  of  nitrate  of  silver  (1  :  10,000  or  1  :  8000).  When  the  effect  is 
good,  the  quantity  of  the  silver  salt  may  be  slowly  and  cautiously 
increased.  As  a  rule,  in  favorable  cases  a  solution  of  1  :  2000  is  soon 
reached  and  is  well  borne  ;  then,  as  improvement  occurs,  the  irrigations 
may  be  discontinued  and  injections  of  a  few  drops  of  solution  of  nitrate 
of  silver  (once  a  day  or  once  every  second  day),  1  :  1000,  500,  and  250, 
may  be  thrown  into  the  anterior  urethra  or  into  its  totality,  according  to 
the  extent  to  which  it  is  involved. 

In  some  cases  it  may  be  well  to  follow  the  silver-nitrate  injections 
for  a  few  times  with  hot  solutions  of  sulphate  of  zinc  and  of  alum,  1  or 
2  :  500  of  each  salt.  The  patient  himself  may  also  use  with  benefit  a 
zinc  and  lead  injection  or  of  any  of  the  salts  previously  mentioned. 

Just  before  the  final  cure  there  will  be  found  an  excess  of  mucus, 
which  floats  as  a  cobweb-like  cloud,  in  the  meshes  of  which  are 
minute  pinpoint-  or  pinhead-sized  granules  of  pus  and  epithelium. 
As  the  morbid  process  ceases  these  granules  disappear,  and  then  for  a 
short  time  there  is  only  a  slight  excess  of  mucus,  which  will,  under 
treatment,  soon  be  reduced  to  its  normal  quantity,  and  then  the  patient 
may  be  pronounced  cured. 

The  treatment  thus  detailed  is  very  simple  and  not  at  all  discomfort- 
ing to  the  patient,  and  with  growing  experience  the  surgeon  will  be 
much  gratified  with  the  excellent  and  permanent  results  which  are 
produced.  By  carefully  examining  the  urine,  especially  the  morning 
specimen,  much  light  is  thrown  on  the  progress  of  the  case,  and  the 
indications  for  the  frequency  and  strength  of  the  silver-nitrate  solution 
may  thus  be  learned.  In  general,  it  may  be  stated  as  the  law  that  so 
long  as  there  is  much  free  pus  and  no  epithelium  in  the  specimen  the 
solutions  should  be  of  the  weaker  grades ;  but  that  as  soon  as  epithelial 
cells  begin  to  appear  the  time  is  ripe  for  progressive  increase  in  the 
strength  of  these  solutions. 

If  this  treatment  is  carefully  carried  out,  the  integrity  of  the  mucous 
membrane  is  restored  and  annoying  relapses  are  not  suffered  from  ;  and 
it  goes  without   saying  that   stricture-formation  is  prevented.     Then, 


68  TREATMENT  OF  ACUTE  GONORRHOEA. 

again,  it  is  unnecessary  to  use  the  antiblennorrhagics  so  freely  and  con- 
stant^ as  we  did  in  years  gone  by,  and  this  is  a  material  gain  for  the 
comfort  of  the  patient. 

With  the  use  of  the  small,  delicate  catheters  no  damage  whatever  is 
done  to  the  urethra,  and  the  compressor  urethrse  muscle  is  not  over- 
taxed and  left  in  an  atonic  condition. 

Treatment  of  Acute  Posterior  Urethritis. 

In  many  cases,  where  the  totality  of  the  urethra  is  involved,  the 
treatment  of  the  posterior  segment  requires  nothing  more  than  the  regu- 
lar treatment  for  acute  anterior  urethritis,  which  has  already  been 
described. 

In  the  milder  forms  of  acute  posterior  urethritis  it  is  well  to  stop  the 
use  of  antiblennorrhagics  and  the  employment  of  injections  into  the 
anterior  urethra,  if  they  give  evidence  of  producing  irritation. 

At  first,  in  the  severe  class  of  cases,  no  local  treatment  should  be 
used.  The  patient  should  be  put  to  bed  and  placed  on  a  milk  diet,  and 
he  should  take  the  alkaline  and  hyoscyamus  mixture.  His  bowels 
should  be  kept  loose  by  the  use  of  mild  cathartics.  In  many  mild  and 
in  some  severe  cases  the  following  mixture  will  produce  much  comfort : 

1^.  Fl.  ext.  tritici  repent., 

Fl.  ext.  uvse  ursi,  ad  §iss  ; 

Liq.  potassae,  gssj 

Tr.  opii,  gtt.  lxiv  to  xcvj  ; 

Aquse,  ad  §iv. 

Dose,  one  teaspoonful  every  three  or  four  hours  in  a  wine-glass  of  water. 
It  is  well,  in  the  milder  order  of  cases,  to  give  laudanum  in  small  doses 
without  producing  any  heaviness  and  sleepiness,  since  it  calms  and 
soothes  the  patient  and  improves  his  morale,  which  is  sometimes  much 
disturbed  by  the  frequency  of  urination,  tenesmus,  and  hematuria.  In 
the  very  severe  cases  hot  sitz-baths,  hot-water  bags  to  the  perineum  and 
perhaps  over  the  pubes,  together  with  tolerably  strong  suppositories  of 
morphine  and  belladonna,  may  be  used  according  to  the  indications.  In 
many  cases  warm  enemata  to  clear  the  rectum,  followed  by  an  injection 
of  cold  water,  will  be  very  beneficial.  It  is  a  good  rule  to  see  that  the 
bowels  are  rendered  free  once  a  day.  Patients  usually  like  large  quanti- 
ties of  water ;  therefore  Apollinaris,  Stafford,  Poland,  and  other  waters 
which  have  a  mildly  demulcent  effect  may  be  freely  allowed.  In  these 
cases  a  moderate  amount  of  alkali  is  usually  beneficial,  but  too  much 
should  not  be  given. 

As  in  anterior  so  in  posterior  urethritis,  we  should  resort  to  local 


TREATMENT  OF  ACUTE  POSTERIOR    URETHRITIS.  69 

medication  just  as  soon  as  we  can  do  so  without  discomfort  to  the  patient 
and  increase  of  the  inflammation.  It  is  well,  therefore,  to  begin  with 
irrigations  of  warm  boric-acid  solution  and  to  proceed  in  the  manner 
directed  on  page  60. 

In  the  severe  cases  it  is  well  to  begin  with  nitrate  of  silver  in  much 
dilution  as  early  as  possible,  and  to  increase  the  strength  of  the  solution, 
which  should  always  be  hot,  until  it  reaches  1  :  8000  or  1  :  4000.  By 
this  time  the  tenesmus  will  be  much  lessened,  the  irritation  less  fre- 
quent, and  the  haematuria  less  copious.  When  these  favorable  symp- 
toms are  progressing  it  is  well  to  use  caution  and  not  to  increase  abruptly 
the  strength  of  the  irrigation.  Later  on,  warm  irrigations  of  alum,  of 
sulphate  of  zinc,  and  of  permanganate  of  potassium  may  perhaps  be  useful 
in  giving  the  parts  a  rest  from  the  action  of  the  nitrate  of  silver.  Under 
favorable  conditions  a  cure  is  produced. 

Under  no  circumstances  should  sounds  or  bougies  be  passed  into  the 
bladder  at  these  times,  since  very  much  harm  may  be  produced  by  them. 
In  the  declining  stage  of  these  mild  cases  the  antiblennorrhagics  in 
moderate  doses  may  be  given  for  a  time,  but  they  should  never  be 
pushed.  The  fluid  extracts  of  kava-kava  and  of  buchu  are  sometimes 
of  seeming  benefit  in  the  declining  stage  of  acute  posterior  urethritis. 

In  some  very  bad  cases  in  which  the  tenesmus  is  dreadful  in  its 
severity  and  the  haematuria  is  copious,  when  other  methods  of  treatment 
have  failed  to  give  relief,  very  often  results  little  less  than  miraculous 
will  be  produced  by  the  instillation  (see  section  on  Treatment  of  Chronic 
Urethritis)  of  a  few  drops  of  a  solution  of  nitrate  of  silver ;  1  :  1000  or 
1  :  500  may  be  given,  care  being  taken  that  the  urethra  is  not  harmed 
by  the  passage  of  the  catheter.  In  using  this  treatment  it  is  well  to  be 
very  careful  to  throw  up  only  a  few  drops  at  first,  and  then  watch  the 
result.  If,  as  sometimes  happens,  the  patient's  sufferings  are  calmed, 
on  the  next  day  or  on  the  second  day  an  injection  of  a  larger  quantity 
may  be  administered.  Usually  in  these  cases  good  will  be  produced  by 
the  1  :  500  solution,  and  caution  should  be  exercised  in  going  higher 
than  that  standard.  But  cases  will  be  encountered  in  which  it  will  be 
necessary  to  use  stronger  solutions,  viz.  :  1  :  250  or  1  :  125. 

Fads  in  the  Treatment  of  Gonorrhoea. — It  is  appropriate  here  to 
call  particular  attention  to  the  tendency  very  prevalent  to-day  to  treat 
gonorrhoea  in  the  acute  stage  in  a  heedlessly  heroic  manner.  We  read 
of  cures  being  produced  in  five,  eight,  twelve,  and  twenty  days,  and 
persons  not  thoroughly  versed  in  the  knowledge  and  treatment  of  gon- 
orrhoea may  be  influenced  by  these  dazzling  and  misleading  claims. 
The  scheme  of  these  treatments  consists  in  the  use  of  some  antiseptic 
drug  (preparations  of  mercury,  silver,  permanganate  of  potassium,  and 
others),  either  in  very  strong  solutions  or  in  irrigations  given  several 


70  TREATMENT  OF  ACUTE  GONORRHOEA. 

times  a  day,  very  hot.  These  treatments  certainly  cut  short  the  severe 
symptoms  and  quite  promptly  cause  the  purulent  discharge  to  become 
mucopurulent.  These  results  are  then  paraded  as  astonishing,  and 
cases  presenting  them  are  looked  upon  as  having  been  cured.  AA7hen 
these  enthusiasts  are  asked  in  what  a  cure  consists,  they  reply,  "  There 
may  be  some  little  redness  of  the  mucous  membrane  left  and  a  little 
sticky  discharge,  but  the  patient  is  all  right."  It  is  hard  to  understand 
how  intelligent  men  can  thus  deceive  themselves.  Many  patients  thus 
treated,  knowing  little  of  gonorrhoea,  consider  themselves  cured ;  others 
see  that  they  are  really  not  cured,  and  they  disappear  and  their  cases 
are  registered  on  the  books  as  cures.  Then,  again,  in  this  sticky  con- 
dition antiblennorrhagics  and  the  usual  astringents  are  used  to  complete 
the  cure ;  but  if  they  are  successful,  the  credit  is  given  to  the  heroic 
remedy  which  calmed  inflammation  and  more  or  less  rapidly  changed 
the  character  of  the  discharge. 

In  the  majority  of  these  cases  there  can  be  no  doubt  the  patients 
are  not  in  any  sense  cured.  They  have  been  rapidly  pushed  into  the 
terminal  stage,  which  in  many  cases  has  no  end.  Now,  if  we  study 
these  cases  carefully  (as,  so  unhappily,  it  is  our  frequent  duty  to  do)  in 
the  light  of  the  pathology  of  the  gonorrheal  process  and  of  their  path- 
ological course,  we  see  that  the  treatment  has  caused  a  much  greater 
exudative  inflammation  into  the  submucous  connective  tissue  than  is 
seen  in  cases  temperately  treated,  and  that  the  catarrhal  inflammation 
has  been  brought  down  from  suppuration  to  the  production  of  a  thick 
mucopurulent  secretion.  This  is  shown  by  the  decidedly  full,  tense, 
and  thickened  condition  of  the  pendulous  and  subpubic  urethra,  and  by 
the  examination  of  the  urine,  which,  strange  to  say,  is  not  insisted  upon 
by  the  authors  of  these  rapid-transit  treatments,  as  they  are  called. 
Then  the  patients,  if  they  have  escaped  epididymitis,  have  symptoms 
of  posterior  urethritis,  urethrocystitis,  and  often  bladder  incompetence, 
and  more  or  less  incontinence.  They  often  further  suffer  from  urine- 
dribbling,  which  is  due  to  the  infiltration  into  the  urethral  walls,  which 
prevents  the  canal  from  performing  the  final  expulsive  acts  of  urination. 
As  time  goes  on  this  exudative  process,  which  involves  nearly  if  not 
all  of  the  anterior  urethra,  and  perhaps  the  posterior  part  also,  produces 
connective  tissue,  and  as  a  result  the  canal  is  more  and  more  constricted, 
until  in  some  very  bad  cases  a  condition  bordering  on  stenosis  is  left, 
accompanied  by  all  the  distressing  conditions  incident  to  blockade  of 
the  bladder.  This  picture  is  not  in  one  particular  overdrawn,  but  is 
based  on  the  unbiassed  study  of  cases  of  acute  gonorrhoea  which  have 
been  railroaded  into  the  terminal  stage.  It  may  be  claimed  by  those 
who  advocate  this  form  of  treatment  that  they  never  see  these  results. 
Perhaps  they  fail  to  appreciate  the  deplorable  condition  the  patients 


THE  METHOD   OF  JANET.  71 

are  left  in ;  but,  as  a  rule,  these  same  patients  think  that  they  have 
had  enough  of  that  sort  of  treatment,  and  have  sense  enough  to  go 
elsewhere. 

The  Method  of  Janet. — A  treatment  of  gonorrhoea  known  as  the 
method  of  Janet  is  now  attracting  considerable  attention  both  in  this 
country  and  abroad.  This  treatment  is  essentially  based  on  the  fact  that 
as  a  result  of  a  certain  technic  the  posterior  urethra  and  the  bladder 
can  be  injected  from  the  meatus  without  the  aid  of  a  catheter.  It  is 
assumed  that  the  catheter  may  not  only  act  as  an  irritant,-  but  that  it  is 
a  fruitful  source  of  infection.  Janet  uses  an  irrigator  or  a  fountain- 
syringe,  to  which  is  attached  about  six  feet  of  India-rubber  tubing  of  30 
F.  calibre.  Into  the  distal  end  of  this  tube  a  goodly-sized  conical  glass 
nozzle  is  inserted,  while  an  India-rubber  stopcock  completes  the  appara- 
tus. The  reservoir  for  the  injection,  whatever  it  may  be,  is  elevated 
above  the  patient  about  two  feet  when  the  anterior  urethra  only  is  irri- 
gated, and  about  four  and  a  half  feet  when  the  posterior  urethra  and 
bladder  are  medicated.  The  patient,  after  urination,  is  placed  on  his 
back  and  the  conical  nozzle  is  well,  but  not  forcibly,  introduced  into  the 
meatus  ;  then  the  current  is  allowed  to  flow. 

If  irrigation  of  the  anterior  urethra  is  practised,  the  stopcock  is  so 
held  that  the  return  current  may  run  out  of  the  meatus  ;  when  the 
deeper  urethra  and  the  bladder  are  to  be  irrigated  the  nozzle  is  firmly 
held  in  the  meatus. 

In  some  cases,  after  a  little  resistance,  the  compressor  urethra?  muscle 
and  the  feeble  external  sphincter  yield,  and  the  injection  flows  through 
the  posterior  urethra  into  the  bladder.  If  the  operation  causes  a  desire 
to  urinate,  the  patient  should  be  allowed  to  evacuate  the  bladder,  and 
then  the  irrigation  should  be  repeated.  For  the  abortive  treatment  of 
acute  anterior  urethritis  one  or  two  irrigations  daily  are  necessarv.  For 
gonorrhoea  of  the  totality  of  the  urethra,  for  the  first  few  days  two 
irrigations  daily  are  given,  and  after  that  only  one  each  day. 

The  therapeutic  agent  employed  by  Janet  is  permanganate  of  potassium 
dissolved  in  warm  water.  The  solutions  vary  in  strength  from  1  :  1000 
of  water  to  1  :  4000.  Toward  the  end  of  treatment,  with  the  decline  of 
the  acute  symptoms,  the  strength  may  be  1  :  500.  For  the  irrigation  of 
the  anterior  urethra  about  one  pint  of  injection  may  be  used,  while  for 
the  bladder  two  lavages  or  irrigations  of  about  a  pint  each  may  be 
introduced. 

By  this  treatment  Janet  claims  that  he  not  only  aborts  incipient 
gonorrhoea,  but  promptly  cures  cases  in  the  acute  purulent  stage.  The 
noticeable  effects  of  these  irrigations,  as  stated  by  Janet  are — first,  the 
appearance  of  a  whitish  secretion,  which  soon  becomes  serous,  and  then 
an  almost  absolute  dryness  of  the  whole  urethral  canal.  In  unsuccessful 
cases  after  this  dry  stage  the  discharge  again  becomes  purulent,  in  which 


72  TREATMENT  OF  ACUTE  GONORRHOEA. 

case  these  lavages  should  be  discontinued  for  eight  days  and  then 
resumed.  Janet  says  that  on  an  average  ten  or  eleven  irrigations  are 
sufficient  to  abort  incipient  cases,  and  nine  for  other  acute  cases  ;  but  in 
general  the  patient  is  cured  by  five  lavages.  As  to  the  stability  and 
validity  of  the  cure,  we  find  these  significant  words  :  "  Sometimes  there 
remains  a  slight  mucous  secretion  ;  "  "  at  other  times  the  patient  has  a 
slight  mucous  discharge,  in  which  case  I  gave  a  little  irrigation  of  nitrate 
of  silver,  1  :  2000,  in  the  anterior  urethra."  It  is  astonishing  how  com- 
placently exploiters  of  abortive  treatments  with  uniformly  favorable 
results  look  upon  these  mucous  secretions  and  fail  to  appreciate  their 
gravity. 

This  treatment  of  Janet  must,  of  necessity,  be  administered  by  the 
surgeon,  to  whom  the  patient  must  come  once  or  perhaps  twice  a  day, 
morning  and  evening. 

The  So-called  Ideal  Substitutes  for  Nitrate  of  Silver. — For 
my  part,  I  hold  to  the  opinion  that  when  it  is  carefully  used  by  a  person 
of  considerable  experience,  nitrate  of  silver  is  the  ideal  agent  in  the 
treatment  of  gonorrhoea  in  nearly  all  stages,  as  indicated  in  the  text. 
Many  substitutes,  however,  have  been  proposed,  and,  although  at  first 
they  were  much  praised,  most  of  them  have  incontinently  failed  and 
have  passed  into  oblivion.  They  come  and  they  go,  but  they  all  have 
advocates  at  first  (De  novis  nil  nisi  bonuiri). 

In  order  to  be  up  to  date,  however,  and  not  to  appear  remiss,  it  is 
necessary  to  mention  some  of  these  agents  which  it  was  expected  would 
revolutionize  the  treatment  of  gonorrhoea.  Argentamine  was  some  time 
ago  recommended  in  solution  1  to  500,  1000,  and  4000,  and,  like  argonin, 
5  to  100,  is  to-day  virtually  discarded.  Largol,  nargol,  and  citrate  of 
silver  have  had  their  vogue  and  are  therapeutical  curiosities.  Ichthyol 
and  ichthargan  were  proclaimed  as  true  destroyers  of  the  gonococcus,  but 
in  practice  they  proved  impotent.  Albargin  still  has  a  few  advocates. 
Protargol  has  had  some  considerable  vogue,  but  like  all  these  hybrid 
essentially  albuminous  nitrate  of  silver  specifics  it  is  a  tame  and  diluted 
agent  as  compared  with  nitrate  of  silver. 

The  latest  substitute  in  local  antiblennorrhagic  therapeutics  for  nitrate 
of  silver  is  argyrol  or  silver  vitelline,  and  it  is  used  in  varying  strengths 
of  from  2  to  5,  even  10  per  cent,  solutions.  It  has  been  carefully  and 
thoroughly  tried  in  my  clinic,  and  the  verdict  is  that  it  produces  no  effect 
that  cannot  be  gotten  from  mild  solutions  of  nitrate  of  silver. 

Medical  men,  particularly  the  younger  ones,  are  always  on  the  look- 
out for  some  gonorrhoeal  specific.  I  place  the  foregoing  list  before  them 
for  their  study  and  delectation. 

These  preparations,  mostly  patented,  are  all  so  extensively  and  per- 
sistently advertised  that  I  have  not  thought  it  necessary  to  occupy  space 
with  their  full  description. 


CHAPTER   V. 

CHRONIC  ANTERIOR  AND  POSTERIOR  GONORRHOEA,   OR 

URETHRITIS. 

In  the  terminal  stage  of  gonorrhoea  the  inflammatory  process  in  very 
many  cases  becomes  localized  in  some  part  of  the  urethra,  and  there 
remains  in  a  latent  or  dormant  state.  There  are  a  number  of  conditions 
which  tend  to  render  the  course  of  gonorrhoea  chronic.  In  the  first 
place,  there  is  the  natural  tendency  of  the  disease  to  linger  indefinitely 
in  the  tissues.  As  we  have  already  seen,  gonorrhoea  is  not  a  simple 
superficial  catarrhal  condition,  but  a  strongly-marked  exudative  and 
catarrhal  inflammation  which  is  very  rebellious  to  our  best-directed 
efforts  in  treatment.  Then,  again,  many  patients  consider  themselves 
cured  just  as  soon  as  the  discharge  ceases,  and  will  submit  to  no  further 
treatment,  though  examination  of  the  urine  shows  the  presence  of  tissue- 
exudates.  Another  and  a  prolific  cause  of  chronic  gonorrhoea — or  gleet, 
as  it  is  called — is  sexual  and  alcoholic  indulgence  during  the  decline  of 
the  chronic  stage.  Still  another  cause  of  the  indefinite  perpetuation  of 
the  disease  is  a  too  active  or  protracted  treatment  by  antiblennorrhagics 
and  injections.  Many  cases  of  chronic  urethritis  are  due  to  the  pro- 
longed physical  exertion  incident  to  the  patient's  occupation.  Chronic 
urethritis  may  be  localized  to  the  anterior  urethra.  Its  symptoms  are 
the  morning  drops — the  pus-accumulation  of  the  night — which  may  be 
small  in  quantity  and  greenish-white  in  color.  There  may  be  a  minute 
drop,  a  large  pea-sized  drop,  or  three  or  more  drops.  In  other  cases 
there  is  simply  gluing  of  the  lips  of  the  meatus  together,  on  the  separa- 
tion of  which  a  film  of  glairy  mucopus  is  seen.  In  other  cases  there  is 
not  sufficient  secretion  to  produce  a  drop.  In  a  third  class  of  cases  there 
is  simply  increased  moisture  at  the  meatus,  and  a  scanty  colorless  secre- 
tion, like  glycerin,  may  be  expressed  by  a  little  pressure. 

There  can  be  no  doubt  that  in  most  cases  of  the  morning  drop  there 
is  an  inflammatory  focus  in  the  anterior  urethra  ;  but  it  does  not  by  any 
means  follow  that  the  posterior  urethra  is  healthy,  since  it  is  frequently 
the  more  active  focus  of  trouble.  In  former  years  gleet  meant,  in  gen- 
eral terms,  chronic  anterior  urethritis,  and  the  treatment  was  based  on 
that  diagnosis.  To-day  we  know  that  chronic  gonorrhoea  of  the  pos- 
terior urethra  is  a  quite  common  affection,  and  that  it  may  exist  alone  or 
in  combination  with  localized  anterior  urethritis. 

73 


74  CHRONIC  ANTERIOR  AND  POSTERIOR   GONORRHOEA. 

A  frequent  combination  is  posterior  urethritis  with  inflammation  of 
the  bulbous  urethra.  Chronic  inflammation  of  the  urethra  at  the  peno- 
scrotal junction  may  exist  alone  or  in  combination  with  posterior  urethritis. 

In  general  terms  it  may  be  said  that  the  morning  drop  is  indicative 
of  trouble  in  the  pendulous  urethra,  the  secretion  of  which  flows  toward 
the  meatus  during  the  night.  During  the  day  the  secretion  may  not  be 
noticeable,  owing  to  the  quite  frequent  flushing  of  the  urethra  by  the 
urine. 

In  many  of  these  cases  of  chronic  anterior  urethritis  all  discharge 
ceases  to  be  seen  at  the  meatus,  and  the  true  state  of  affairs  can  only  be 
ascertained  bv  the  examination  of  the  urine,  or  by  the  use  of  the  endo- 
scope. If  distinctly  limited  to  the  anterior  urethra,  the  urine  in  the  first 
glass  will  contain  threads  or  masses  of  tissue-products,  and  that  in  the 
second  glass  will  be  clear.  In  all  cases,  however,  the  examination  should 
be  pushed  still  farther :  the  anterior  urethra  should  be  carefully  and 
fully  irrigated,  and  then  the  urine  should  be  passed  into  one  or  two 
glasses.  In  the  fluid  which  has  been  used  in  irrigation  will  be  found 
the  products  of  inflammation  of  the  anterior  urethra,  and  in  the  first 
glass  those  of  the  posterior  urethra  if  it  is  the  seat  of  inflammation. 

In  the  bulbous  urethra  the  gonorrheal  process  shows  a  marked  ten- 
dency to  become  chronic,  and  its  persistency  causes  it  to  be  very  rebel- 
lious to  treatment.  In  this  part  of  the  urethra  the  vascular  supply  is 
so  great,  the  tissues  are  so  succulent,  and  we  may  say  relaxed,  that  every 
condition  favorable  to  chronic  inflammation  is  present. 

Chronic  urethritis  of  the  bulbous  urethra  may  give  rise  to  no  secre- 
tion visible  at  the  meatus.  Then,  again,  the  pus  may  be  so  copious  and 
fluid  in  consistence  that  it  may  glue  up  the  meatus  in  the  morning  and 
perhaps  during  the  day,  or  may  escape  once  a  day  or  oftener  as  a  decided 
drop.  Owing  to  the  fact  that  the  bulbous  portion  is  in  direct  continuity 
with  the  membranous  urethra,  this  portion  may  be  the  seat  of  hyperemia 
or  inflammation  in  bulbous  urethritis. 

A  chronic  discharge,  usually  small  in  amount  and  viscid  in  consist- 
ence, may  be  developed  as  a  result  of  chronic  gonorrhoeal  inflammation 
of  the  glands  of  Littre  and  the  crypts  of  Morgagni.  In  these  cases  the 
lacuna  magna  and  other  large  follicles  may  be  the  seat  of  inflammation. 
Chronic  follicular  urethritis  is  usually  uncomplicated  with  posterior 
urethritis.  It  is  found  on  the  lips  of  the  meatus,  just  within  that  orifice, 
and  as  far  down  as  the  bulb. 

Chronic  inflammation  of  Cowper's  glands  has  been  known  to  cause  a 
discharge  into  the  urethra  which  was  intermittent  in  character.  In 
some  cases  of  chronic  anterior  urethritis  the  patient  suffers  no  inconve- 
nience whatever.  In  a  few  cases  the  patients  complain  of  pain  localized 
at  some  part  of  the  urethra. 


CHRONIC  ANTERIOR  AND  POSTERIOR   GONORRHOEA  75 

Chronic  posterior  urethritis  follows  in  many  cases  the  subsidence  of 
the  acute  process.  Owing  to  the  complexity  of  structure  of  the  pos- 
terior urethra  the  symptomatology  of  this  affection  is  often  quite  well 
marked.  When  there  is  simply  uncomplicated  chronic  inflammation  of 
the  mucous  membrane  the  symptoms  may  be  negative  or  very  slight  in 
character. 

It  is  very  important  to  emphasize  the  statement  that  many  cases  of 
chronic  posterior  urethritis  are  much  prolonged  by  reason  of  a  coexistent 
chronic  catarrhal  prostatitis  (see  sections  on  this  subject,  p.  288),  and 
chronic  inflammation  of  the  verumontanum.  The  same  statement 
applies  to  the  seminal  vesicles.  Not  infrequently  these  structures  are 
invaded  during  the  course  of  acute  gonorrhoea  of  the  totality  of  the 
urethra,  and  on  the  decline  of  the  process  chronic  posterior  urethritis  is 
left,  together  with  a  chronic  inflammation  of  the  seminal  vesicles.  It  is 
most  important  in  all  cases  of  chronic  posterior  urethritis  to  ascertain 
whether  these  deep-seated  conditions  exist  as  complications. 

In  chronic  urethritis  distinctly  limited  to  the  posterior  urethra  there 
is  usually  no  escape  of  pus  into  the  anterior  portion,  for  the  reason  that 
it  is  small  in  quantity  and  viscid  in  consistency.  There  are,  however, 
border-line  cases  in  the  extreme  terminal  stage  of  the  acute  affection  in 
which  the  pus  is  still  rather  copious,  and  it  escapes  through  the  mem- 
branous urethra  and  passes  toward  the  meatus.  The  compressor  urethrse 
muscle  does  not  usually  contract  the  lumen  of  the  urethra  to  a  hair-sized 
calibre,  as  claimed  by  some  authors,  and  in  general  it  is  a  moderately 
patulous  canal  at  this  point.  There  certainly  is  not,  in  the  majority  of 
cases,  such  a  tonicity  of  the  compressor  urethrse  muscle  as  will  keep 
back  a  quite  copious  discharge.  While  in  many  cases,  owing  to  its 
small  quantity,  the  pus  may  be  retained  in  the  posterior  urethra  by  the 
cut-off  muscle,  in  some  cases  it  certainly  is  not  thus  dammed  backward. 
The  cases  of  chronic  posterior  urethritis  in  which  a  discharge  reaches 
the  meatus  are  very  rare,  but  they  occur. 

In  very  many  cases  of  posterior  urethritis,  there  being  no  visible 
discharge  and  the  patients  complaining  of  no  symptoms  referable  to  the 
deep  urethra,  the  affection  remains  dormant  and  unrecognized.  Thus 
the  cases  may  drag  on  for  one  or  more,  or  even  five,  ten,  and  twenty, 
years  without  giving  any  indication  of  lurking  trouble.  In  some  of 
these  cases  an  exacerbation  occurs,  and  then  the  patient  realizes  that  he 
has  had  an  uncured  gonorrhoea. 

In  some  instances  the  exacerbation  of  the  posterior  urethritis  is  sub- 
acute in  character,  attended  only  with  mild  or  insignificant  symptoms, 
and  its  presence  would  not  be  suspected  or  sought  for  had  not  an  attack 
of  epididymitis  or  epididymo-orchitis  developed  as  a  complication.  In 
many  cases  of  this  deep-seated  urethritis,  in  which  epididymitis  or  epi- 


76  CHRONIC  ANTERIOR  AND  POSTERIOR   GONORRHOEA. 

clidymo-orchitis  was  developed  in  the  initial  attack,  recrudescences  in 
the  testicular  trouble  are  frequently  developed  at  late  and  remote  periods 
as  a  result  of  an  exacerbation  in  the  posterior  urethritis. 

In  somewhat  rare  instances  chronic  posterior  urethritis,  usually  as  a 
result  of  excesses,  becomes  developed  into  a  true  acute  attack  with  all 
its  symptoms  and  its  discomforts.  It  may  thus  run  its  course ;  but  in 
some  cases  the  inflammatory  process  extends  forward  into  the  anterior 
urethra,  which  also  becomes  the  seat  of  an  acute  phlegmasia.  In  these 
cases,  when  the  discharge  is  well  established  in  the  anterior  urethra, 
the  sufferings  of  the  patient,  experienced  when  the  posterior  segment 
alone  was  affected,  cease,  and  the  case  then  takes  on  the  features  of  a 
gonorrhoea  of  the  totality  of  the  urethra  in  its  declining  stage. 

What  has  already  been  said  as  to  the  means  of  recognizing  the  exist- 
ence of  acute  posterior  urethritis  applies  with  equal  force  to  the  diagno- 
sis of  the  chronic  affection.  In  this  connection  it  is  well  to  remember 
that  small,  comma-like  fleecy  plugs  or  threads,  which  are  thought  to  be 
formed  in  the  excretory  ducts  of  the  prostatic  glands  and  voided  with 
the  last  drops  of  urine,  being  pressed  out  by  muscular  and  prostatic 
contraction,  are  quite  diagnostic  of  chronic  posterior  urethritis. 

Symptoms. — The  symptoms  of  chronic  posterior  urethritis  are  many 
and  varied,  mild  and  severe. 

Cases  of  this  affection  may  be,  for  purposes  of  study,  separated  into 
groups  according  to  the  nature  and  severity  of  their  symptoms. 

There,  is  found  in  practice  a  goodly  number  of  cases  in  which  a  fre- 
quent desire  to  urinate  and  some  uneasiness  at  the  end  of  the  act,  and 
sometimes  at  its  beginning,  are  the  only  symptoms  complained  of.  In 
some  of  these  cases  the  increased  frequency  in  urination  is  not  much 
above  normal ;  in  others  it  is  well  marked.  In  some  cases  the  pain  is 
slight  and  mild,  or  of  a  quick,  stabbing,  but  very  ephemeral  character. 
In  others  it  is  dull,  heavy,  perhaps  spasmodic,  and  radiates  into  the 
rectum,  pelvis,  testes,  and  groins.  In  these  cases  the  act  of  urination 
may  go  on  smoothly,  or  it  may  be  interrupted  by  slight  or  severe  spasm 
of  the  compressor  urethra?  muscle  or  of  the  detrusor  vesicas  muscles. 
This  condition  has  been  called  "  cystospasmus."  It  is  liable  to  occur 
after  coitus  or  difficult  defecation.  In  other  cases  there  is  no  disturb- 
ance of  urination  at  all,  but  patients  complain  of  dull  or  aching  pain 
in  the  perineum,  deep  in  the  pelvis  and  prostate,  and  in  the  rectum. 
Sometimes  these  patients  complain  of  pain  over  the  pubes  and  of  uneasy, 
vague  pains  in  the  cord  and  testes.  In  some  cases  mild  and  even  severe 
neuralgic  pains  are  complained  of  in  the  loins,  groins,  and  thighs.  These 
painful  symptoms,  particularly  when  severe,  are  fortunately  not  con- 
tinuously present.  They  vary  from  day  to  day,  so  that  the  patient  has 
intervals  of  comparative  comfort. 


CHRONIC  ANTERIOR  AND  POSTERIOR   GONORRHOEA.  77 

Perhaps  the  most  serious  and,  for  the  physician,  trying  cases  of  pos- 
terior urethritis  are  those  in  which  the  prostate  and  its  sexual  apparatus 
are  involved  and  there  is  some  disturbance  of  the  sexual  function.  Some 
patients  complain  of  a  severe  stabbing  pain  at  the  moment  of,  or  after, 
ejaculation  of  the  semen.  Others  state  that  all  pleasurable  sensations 
are  either  absent  or  lessened  in  degree  in  sexual  intercourse,  and  they 
are  thereby  much  worried.  In  still  other  cases  the  ejaculations  occur 
before  intromission  or  shortly  afterward. 

In  some  cases  pollutions  are  frequent,  and  with  their  occurrence  a 
diminution  in  the  sexual  appetite  is  felt.  Many  of  the  patients  become 
weak,  nervous,  and  apprehensive.  Their  digestion  becomes  poor,  and 
they  suffer  from  constipation.  Then  the  passage  of  a  hard  fecal  plug 
presses  on  the  prostate  and  expels  the  accumulated  mucopus,  which 
appears  at  the  meatus,  causing  the  patient  to  think  he  is  losing  semen. 
In  some  of  these  cases  some  of  the  secretion  of  the  seminal  vesicles  is 
at  the  same  time  expelled,  and  this  also  to  many  is  convincing  proof  that 
they  are  suffering  from  spermatorrhoea.  Occasionally  these  patients  are 
much  alarmed  at  the  occurrence  of  bloody  pollutions,  which  are  due  to 
great  hyperemia  of  the  ejaculatory  ducts.  In  any  of  these  cases  of 
disturbance  of  the  sexual  function  we  are  liable  to  find  more  or  less 
deterioration  of  the  health.  This  may  consist  simply  of  weakness  and 
lassitude,  and  it  may  be  a  condition  of  great  nervousness,  of  melancholia, 
or  even  of  true  neurasthenia.  Between  these  two  extremes  there  are 
many  degrees  of  bodily  and  mental  debility. 

Pathology. — Gonorrhoea  not  only  produces  a  chronic  catarrhal  con- 
dition, but  also  a  severe  exudative  inflammation  in  the  submucous  con- 
nective tissue  results,  which  has  a  tendency,  if  the  process  persists  for  a 
long  time,  to  damage  the  urethra  permanently.  Such  an  exudative 
inflammation  induced  by  the  gonococcus  is  attended  first  with  a  des- 
quamation of  the  urethral  epithelium,  and  when  this  epithelium  is 
restored  it  is  liable  to  be  more  or  less  thickened  and  to  have  a  different 
character  from  the  normal  epithelium  of  the  urethra.  In  other  words, 
the  normal  cylindrical  epithelium  of  the  urethra  becomes  destroyed  by 
the  gonorrhceal  process,  and  is  on  healing  replaced  by  flat  pavement- 
epithelium.  These  epithelial  proliferations  are  seen  by  the  endoscope 
to  appear  like  granular  and  warty  patches,  and  even  polypoid  growths. 
When  old  they  may  present  a  whitish,  opaque  appearance  resembling 
cicatrices.  Then,  again,  the  exudative  inflammation  attending  gonor- 
rhoea may  produce  ulcers  or  erosions,  and  frequently  induces  a  formation 
of  connective  tissue  in  the  walls  of  the  urethra.  The  mucous  glands 
may  also  be  considerably  changed.  Figs.  19  and  20  show  the  character 
of  the  gonorrhceal  inflammation,  and  Fig.  21  illustrates  some  of  the 
more  important  sequela?  of  chronic  gonorrhoea. 


78 


CHRONIC  ANTERIOR  AND  POSTERIOR   GONORRHOEA. 


Showing   a  transverse  section  through  the  entire  urethral  canal  and  tunica  albuginea,  with 
round-cell  infiltration  around  urethra  and  mucous  follicles. 

Figs.  19  and  20  were  taken  from  sections  of  the  urethra  of  a  subject 
who  had  had  chronic  gonorrhoea  for  some  months.  In  Fig.  19  the  topo- 
graphical distribution  of  the  inflammation  is  shown  in  a  section  through 

Fig.  20. 


-■ P 


Showing  a  segment  of  roof  of  urethra,  with  round-cell  infiltration  of  the  mucosa  and  tubular  ducts 
of  follicles  ;  higher  magnifying  power  than  in  Fig.  19. 


CHRONIC  ANTERIOR   AND  POSTERIOR   GONORRHOEA. 


79 


the  entire  thickness  of  the  urethral  canal,  including  the  tunica  albuginea. 
The  whole  folded  lumen  of  the  urethra  is  surrounded  by  a  deep  ring  of 
small  round-cells  (z),  which  seem  mainly  to  have  come  from  the  super- 
ficial vessels  of  the  mucosa,  while  a  part  of  them  may  be  proliferated 
connective-tissue  cells.  The  epithelial  lining  of  the  urethra  is  des- 
quamated, and  is  entirely  absent  in  places  (x,  x,  x),  while  in  other  places 
(y,  y)  it  is  still  in  proper  position,  although  infiltrated  with  pus-cells. 
In  the  roof  of  the  urethra,  in  this  section,  the  ducts  of  the  mucous 
glands  at  various  depths  are  also  surrounded  by  a  heavy  infiltration  of 
small  round-cells,  which  indicates  an  extension  of  the  inflammation 
along  the  mouths  of  the  glands  from  the  surface  of  the  urethra  (w,  iv). 

Fig.  21. 


Showing  an  exulceration  of  the  urethra,  with  round-cell  infiltration-bed  and  absence  of  epithe- 
lium ;  newly-formed  capillaries  in  red. 


Fig.  20  shows  the  invasion  of  the  urethra  by  the  gonorrhceal  process 
still  more  plainly.  The  drawing  includes  the  whole  thickness  of  a  seg- 
ment from  the  roof  of  the  urethra,  corresponding  to  the  rectangular  area 
indicated  byp,  q  in  Fig.  19.  With  this  higher  magnifying  power  in 
Fig.  20  the  infiltration  of  the  mucosa  and  tissue  surrounding  the  tubular 
ducts  of  the  mucous  glands  is  shown  in  detail.  AVith  the  exception  of 
the  patches  denoted  by  x  and  y,  the  epithelial  lining  of  the  urethra  is 
absent,  so  that  there  are  extensive  areas  of  erosion  of  the  infiltrated 
mucosa. 

Lying  free  in  the  urethral  lumen  near  the  denuded  surface  is  a  flake 
of  the  gonorrhoeal  exudation  (z,  z,  Fig.  20).  This  flake  is  quite  identical 
in  structure  with  the  ordinary  gonorrhoeal  discharge  as  seen  on  a  cover- 
glass,   and   consists   mainly   of  pus-cells   lying   in   a  fluid  or  granular 


80  CHRONIC  ANTERIOR  AND  POSTERIOR   GONORRHOEA. 

matrix.  The  mucosa  just  beneath  what  is  left  of  the  epithelial  lining 
is  very  densely  crowded  with  small  round-cells  to  the  extent  shown  in 
the  figure  at  v,  v. 

In  the  same  way  the  ducts  of  the  mucous  glands  u,  w,  and  r,  and  in 
places  the  gland  acini  themselves  (t),  are  similarly  infiltrated  with  the 
small  round-cells.  The  ducts  w  and  r  have  their  lumina  partially  filled 
with  desquamated  cells  and  granular  material. 

These  figures  (19  and  20),  then,  serve  to  show  that  when  gonorrhoea 
has  become  chronic  it  must  necessarily  take  a  long  time  for  the  disease 
to  heal,  since  in  the  affected  regions  of  the  urethra  all  this  desquamated 
epithelium  must  be  restored,  and  the  infiltration  of  small  round-cells  be 
absorbed  before  the  urethra  can  become  healthy  again. 

Among  the  most  important  sequelse  of  gonorrhoea  are  ulcers  or  ero- 
sions of  the  urethra,  which  are,  as  a  rule,  small  and  sharply  localized. 
Fig.  21  shows  a  longitudinally  situated  narrow  linear  ulcer  from  the 
middle  of  the  penile  urethra.  The  section  was  cut  transversely  through 
the  urethra.  As  far  as  the  structure  of  this  ulcer  is  concerned,  it  needs 
but  little  description,  for  it  does  not  differ  essentially  from  minute  ulcers 
elsewhere  in  the  skin  or  mucous  membranes  approaching  the  skin  in 
structure.  At  the  site  of  the  ulcer  the  epithelium  is  deficient ;  there  is 
a  fairly  circumscribed  collection  of  small  round-cells,  interspersed  with 
newly-formed  capillaries,  which  tend  to  pass  up  vertically  toward  the 
surface.     In  a  word,  the  ulcer  has  a  bed  of  granulation-tissue. 

The  practical  importance  of  such  a  condition  of  the  urethra  is  that 
it  tends  to  persist  almost  indefinitely,  and  keep  up  a  discharge  which 
appears  as  a  scanty  gleet  or  a  discouragingly  prolonged  appearance  of 
gonorrhoea!  threads. 

The  morbid  process  in  chronic  posterior  urethritis  is  essentially  the 
same  as  that  which  affects  the  anterior  urethra — namely,  a  small-cell 
exudative  inflammation  into  the  submucous  connective  tissue.  This 
small-cell  infiltration  may  be  superficial  and  only  involve  the  connec- 
tive-tissue layer,  or  it  may  extend  deeper  into  the  structural  parts  of  the 
prostatic  urethra.  In  the  superficial  form  of  infiltration  the  lesion  only 
involves  the  upper  layers  of  the  subepithelial  connective  tissue,  and 
does  not  result  in  much  condensation  of  the  membrane.  In  the  deeper 
form  the  whole  subepithelial  stratum  is  involved,  and  the  caput  gallina- 
ginis,  the  sinus  pocularis,  the  openings  of  the  ejaculatory  ducts,  and  the 
glands  of  the  posterior  urethra  may  also  be  more  or  less  implicated  in 
the  cell-infiltration,  and  their  structure  and  function  more  or  less  dam- 
aged and  impaired.  All  these  structures  may  be  invaded  in  precisely 
the  same  manner  as  the  racemose  mucous  glands  of  the  anterior  urethra 
are. 

Where  the  cell-infiltration  is  very  extensive  and  deep,  the  prostatic 


MORBID  CHANGES  SEEN  BY  MEANS  OF  THE  ENDOSCOPE,     81 

urethra  becomes  more  or  less  callous  and  dense.  The  picture  seen  by 
the  naked  eye  of  chronic  posterior  urethritis  is  sometimes  a  granular 
condition  due  to  epithelial  thickening,  and  perhaps  a  slightly  warty  con- 
dition due  to  the  presence  of  minute  new  vessels  covered  with  thickened 
epithelium.  In  later  stages  the  caput  gallinaginis  is  seen  to  be  enlarged 
and  covered  by  callosities  formed  by  the  heaping  up  of  pathological 
epithelial  layers.  As  a  result  of  these  lesions  we  find  evidences  of  a 
persistent  desquamative  catarrh.  Owing  to  these  changes  the  dilata- 
bility  of  the  prostatic  urethra  is  somewhat  impaired,  and  its  lumen  is 
perhaps  slightly  impinged  upon  by  the  epithelial  thickening  and  by  the 
increased  size  of  the  caput  gallinaginis ;  but  there  is  no  such  condition 
(though  the  parts  may  have  even  become  cirrhotic)  of  stricture,  such  as 
we  find  in  the  anterior  urethra. 

Morbid  Changes  Seen  by  Means  of  the  Endoscope. — The  patho- 
logical appearances  of  chronic  urethritis,  as  revealed  to  the  eye,  are 
quite  varied,  and  in  the  main  striking. 

By  the  use  of  the  endoscope  the  morbid  appearances  of  the  urethra 
are  well  shown.  In  general  it  may  be  said  exploration  of  the  urethra 
by  the  endoscope  should  be  confined  to  the  anterior  urethra,  which  may 
thus  be  examined  without  damage  and  detriment  to  the  patient.  The 
condition  of  the  posterior  urethra  can  be  so  well  determined  by  the 
examination  of  the  urine  and  by  rectal  exploration  of  the  prostate,  and 
in  many  cases  by  a  consideration  of  the  symptoms,  that  endoscopy, 
which  is  (except  to  skilled  experts)  a  difficult  procedure  and  often  fol- 
lowed by  local  injury,  should  only  exceptionally  be  resorted  to. 

Chronic  urethritis  of  the  follicles  shows  itself  in  small  deep-red  pus- 
oozing  spots  of  the  size  of  a  pinhead  to  that  of  a  pea.  The  lacuna 
magna  and  similar  crypts  may  thus  show  evidence  of  inflammation,  or 
the  orifices  of  the  follicles  of  Littre  may  be  involved. 

The  most  constant  morbid  condition  seen  in  chronic  anterior  urethritis 
is  a  rather  deep-red,  even  purplish,  color  of  the  mucous  membrane,  which 
is  more  or  less  thickened  and  velvety.  This  redness  may  involve  a  seg- 
ment of  the  canal  or  a  limited  portion  on  one  or  two  sides  of  the  canal. 
In  these  cases  more  or  less  pus,  thin  or  inspissated,  may  be  seen  in  the 
examination.  Thickened  red  circumscribed  spots  or  plaques  of  chronic 
inflammation  are  very  common.  The  next  appearance  quite  commonly 
seen  is  called  by  some  granular  urethritis.  The  membrane  is  thickened, 
red,  even  purplish  in  streaks,  and  rough  and  studded  with  small  projec- 
tions, which  consist  either  of  epithelial  hyperplasia  or  of  little  eminences 
caused  by  the  growth  of  new  capillary  vessels.  This  condition  is  fre- 
quently found  in  the  bulbous  urethra  and  also  in  the  pendulous  portion. 

A  further  advanced  form  of  this  granular  urethritis  is  called  papillo- 
matous urethritis,  in  which  minute  but  distinctly  defined  raspberry-like 
6 


82  CHRONIC  ANTERIOR  AND  POSTERIOR   GONORRHOEA. 

masses  of  new  growth  are  scattered  over  a  segment  of  the  canal.  In 
some  cases  there  may  be  but  one  tuft  of  papilloma,  and  in  others  there 
may  be  many  such.  These  little  new  growths  are  formed  of  round-cell 
infiltrations,  new  capillaries,  and  epithelial  hyperplasia.  They  are 
usually  found  a  few  inches  from  the  meatus  and  as  far  down  as  the 
bulbous  expansion  of  the  urethra.  Since  the  most  careful  passage  of  a 
soft  bougie  or  catheter  in  cases  of  papillomatous  urethritis  will  often 
cause  slight  bleeding,  the  occurrence  of  this  symptom  may  lead  to  a 
suspicion  of  its  cause. 

Erosions  and  ulcerations  of  the  urethra  are  frequently  the  cause  of 
chronic  urethritis.  In  the  erosive  form  the  mucous  membrane  is  thick- 
ened and  red,  and  in  spots  the  epithelium  is  seen  to  be  lost.  Ulcers  of 
the  urethra  are  usually  small  and  sharply  limited,  and  the  evidence  of 
loss  of  tissue  can  be  clearly  made  out.  The  erosive  form  and  the  ulcer- 
ative form  of  chronic  urethritis  may  coexist,  and  may  involve  only  a 
limited  portion  of  the  urethra.  Then,  again,  we  sometimes  see  involve- 
ment of  a  considerable  segment  of  the  canal  in  redness  and  swelling, 
which  is  studded  here  and  there  with  erosions  and  ulcers  and  granular 
and  papillomatous  growths. 

The  morbid  appearances  of  the  mucous  membrane  of  the  posterior 
urethra  are  not  conspicuously  striking.  They  consist  of  thickening, 
more  or  less  papillation,  together  with  increased  redness.  Frequently 
the  caput  gallinaginis  and  the  orifices  of  the  prostatic  ducts  are  seen  to 
be  swollen.  The  underlying  pathological  process  is  precisely  similar  to 
that  of  the  anterior  urethra.  In  the  threads  which  contain  pus  and 
epithelium  of  various  kinds,  gonococci  are  rather  infrequently  found. 


CHAPTER    VI. 

TREATMENT  OF  CHRONIC  ANTERIOR  AND  POSTERIOR 

GONORRHOEA. 

When  gonorrhoea,  or  urethritis,  has  lasted  beyond  four  months, 
and  is  then  in  a  decidedly  subacute  condition,  it  may  be  called  chronic. 

In  the  treatment  of  chronic  gonorrhoea  the  history  of  the  case  must 
be  carefully  considered.  Then  it  is  necessary  to  determine  the  seat  and 
extent  of  the  morbid  process  and  its  nature  and  physical  character.  In 
every  case  the  first  diagnostic  points  should  be  obtained  by  the  careful 
examination  of  the  urine.  At  the  first  examination  instruments  for 
diagnostic  purposes  should  be  guardedly  used. 

The  disease  lurks,  particularly  in  very  chronic  cases,  in  various  parts 
and  exists  under  different  conditions,  so  that  there  are  scarcely  two  cases 
which  thoroughly  resemble  each  other.  The  consequence,  therefore,  is 
that  there  is  no  specifically  routine  treatment  for  chronic  urethritis,  but 
each  case  must  be  treated  on  the  basis  of  its  morbid  process  and  of  the 
therapeutic  indications  presented  by  it. 

The  duration  of  the  urethritis  has  an  important  bearing  upon  its 
treatment.  Let  us  first  consider  the  cases  in  which  the  disease  has  lasted 
only  a  few  months.  Such  patients  may  complain  only  of  the  morning 
drop,  or  they  may  state  that  they  seem  well  so  long  as  they  use  an  injec- 
tion, abstain  from  coitus,  and  do  not  drink  beer  and  alcoholics  or  eat 
highly-seasoned  food.  When  they  cease  injecting  and  indulge  in 
creature  comforts  and  excesses,  the  morning  drop  reappears,  with  per- 
haps a  more  or  less  profuse  discharge  during  the  whole  day.  Examina- 
tion of  the  urethra  in  these  cases  shows  a  catarrhal  and  exudative 
condition  from  the  bulb  forward,  perhaps  nearly  to  the  meatus.  In 
many  of  these  cases  the  posterior  urethra  is  also  involved.  The  morn- 
ing urine  is  rather  cloudy,  like  turbid  cider,  contains  much  mucus,  and 
some  long  thin  or  thick  threads  (sometimes  three  or  four  inches  long). 
There  may  or  may  not  be  a  few  gonococci  present.  In  these  cases 
the  best  treatment  is  irrigation  of  the  anterior  and  posterior  urethra;, 
using  at  first  warm  solutions  of  alum  and  sulphate  of  zinc,  beginning 
with  a  strength  of  1  :  500,  and  increasing  according  to  the  result 
obtained.  Usually  one  irrigation  daily  is  sufficient,  but  perhaps  two 
may  be  well  borne.     The  sensations  of  the  patient  and  the  condition  of 

83 


84 


TREATMENT  OF  CHRONIC  GONORRHOEA. 


the  urine  are  infallible  guides  as  to  the  required  frequency  of  treatment. 
As  a  general  rule,  after  one  or  two  weeks'  treatment  these  irrigations 
seem  to  lose  their  efficacy,  having  done  some  good,  but  not  having  pro- 
duced a  cure.  Perhaps  in  these  conditions  permanganate-of-potassa 
irrigations  (always  quite  hot),  1  :  1000  or  1  :  2000,  may  bring  about  a 
cure.  If  this  remedy  fails,  we  resort  to  nitrate  of  silver,  beginning 
with  solutions  of  the  strength  of  1  :  16,000  or  1  :  8000,  and  sometimes 
even  weaker :  and  this  usually  brings  about  a  cure  if  the  treatment  is 
carefully  administered.  If  the  morbid  process  is  more  severe  in  the 
anterior  urethra,  the  bulbous  reflux  catheter  (see  Fig.  15)  should  be 
introduced  as  far  as  the  bulb,  one  or  two  hand-syringefuls  of  the  irri- 
gating fluid  should  be  injected.  The  posterior  urethra  should  then  be 
similarly  treated.  Sometimes  it  is  necessary  to  finish  with  quite  strong, 
deep  injections.  In  these  cases  much  pain  is  frequently  produced  by 
the  passing  of  sounds,  particularly  of  large  ones.  This  fact  should 
always  be  borne  in  mind,  since  many  patients  thus  treated  suffer 
severely,  while  in  others  the  disease  is  so  aggravated  that  it  is  most 
difficult  to  cure.  Some  of  these  cases  are  rendered  practically  incur- 
able even  if  the  most  judicious  and  prolonged  treatment  is  followed. 
Too  much  attention  cannot  be  paid  to  the  fact  that  in  some  cases  of 
chronic  gonorrhoea  sounds  may  be  productive  of  incalculable  harm. 

When  the  disease  is  limited  to  the  bulbous  portion,  where  it  shows  a 
great  tendency  to  remain  indefinitely,  the  retrojections  of  alum,  sulphate 
of  zinc,  and  nitrate  of  silver  may  be  used.  These  injections  will  mate- 
rially modify  the  morbid  process,  and  sometimes  cure  it,  but  they  often 
fail  to  bring  about  a  thorough  cure.  In  that  event  it  is  well  to  make 
direct  local  application  of  solutions  of  nitrate  of  silver,  beginning  with 
a  solution  of  1  :  2000,  and  perhaps  going  as  high  as  1  :  250.      These 

Fio.  22. 


Author's  syringe. 


injections  may  be  given  by  means  of  my  syringe  which  is  very  easily 
worked,  having  a  ring  and  shoulders  for  the  thumb  and  fingers,  and  a 
very  conical  nozzle,  which  will  fit  into  any  small  soft  catheter.  The 
piston  is  marked  with  numbers  to  regulate  the  drops.  The  injecting 
medium  is  any  well-made  soft-rubber  catheter,  10  to  12  or  14  French, 
cut  off  to  measure  eight  and  a  half  inches  in  length,  or  the  reflux  cath- 
eter may  be  used.     When  the  catheter  is  introduced  six  or  six  and  a 


TREATMENT  OF  CHRONIC  GONORRHOEA.  85 

half  inches,  its  end  is  in  the  sinus  of  the  bulb,  and  the  very  slight 
impediment  it  encounters  there  shows  the  operator  that  he  is  just  at  the 
opening  in  the  triangular  ligament.  The  little  catheter  being  slowly 
passed,  never  causes  pain  or  irritation.  Then  ten  or  fifteen  drops  of 
the  silver-nitrate  solution  may  be  thrown  into  the  urethra.  This  treat- 
ment may  be  administered  by  the  surgeon  every  five  days  or  twice  a 
week,  and  perhaps  oftener  if  the  indications  of  the  case  point  to  the 
necessity  of  increased  frequency.  In  the  intervals  the  patient  may  use 
mild  stimulant  and  astringent  injections  by  means  of  the  penis-syringe. 
This  form  of  chronic  urethritis  being  very  rebellious,  it  is  sometimes 
necessary  to  pass  an  endoscopic  tube  down  to  the  bulb,  and  having 
ascertained  the  morbid  appearances,  to  apply  sparingly  on  cotton  at 
the  end  of  an  applicator  a  strong  solution  of  silver  nitrate  (gr.  30  to 
Sj   water). 

In  the  more  chronic  cases  of  anterior  urethritis  we  find  spots,  patches, 
and  areas  of  inflammation  at  the  penoscrotal  angle  (sometimes  seemingly 
caused  by  the  pressure  of  the  suspensory  worn  during  the  declining 
stage)  and  in  the  pendulous  urethra  as  far  as  its  beginning. 

The  first  essential  in  the  treatment  of  these  cases  is  to  locate  the 
trouble  and  to  determine  its  nature. 

Now,  it  must  be  distinctly  understood  that  all  of  the  above-men- 
tioned inflammatory  conditions  cause  a  greater  or  less  thickening  of  the 
urethral  walls,  and  they  impinge  more  or  less  upon  its  calibre.  There 
is  a  very  prevalent  tendency  nowadays  to  call  any  condition  which  may 
interfere  with  the  easy  passage  of  the  bougie  a  boule  forward  or  back- 
ward a  stricture,  and  thousands  of  men  have  been  cut  for  stricture 
when  they  had  only  one  or  more  of  the  above-mentioned  conditions. 
A  little  thickened  patch  of  infiltrated  mucous  membrane,  perhaps  seated 
on  one  side  of  the  canal  or  perhaps  encircling  it,  will  prove  an  obstacle 
to  the  easy-sliding  forward  and  backward  of  the  bulb,  and  the  case 
might  be  mistaken  for  one  of  annular  stricture  of  large  calibre.  An 
ulcer  or  erosion  with,  its  concomitant  thickening  will  offer  some  resist- 
ance, and  the  bulb  on  its  return  may  jump  and  jerk  over  it.  The  epi- 
thelial hyperplasias  wnich  often  accompany  submucous  infiltration  jut 
up  in  the  canal  and  more  or  less  narrow  its  calibre  and  impair  its  supple- 
ness. A  swollen  follicle  may  act  in  a  similar  mannei*.  fPapillomata 
will  offer  more  or  less  resistance,  but  as  they  bleed,  so  readily  even  on 
gentle  manipulation,  their  nature  may  be  suspected.  AH  inflammatory 
conditions  render  the  urethra,  particularly  its  pendulous  portion,  thick- 
ened, less  supple,  and  more  or  less  impinge  on  its  calibre  and  destroy 
its  expansibility.  Bearing  these  facts  in  mind,  it  is  a  very  serious 
matter  to  decide  without  full  painstaking  examinations  that  a  man  has 
stricture. 


86  TREATMENT  OF  CHRONIC  GONORRHOEA. 

The  Use  of  the  Bougie  a  Boule. — In  these  cases  much  aid  can  be 
obtained  as  to  location  by  the  bougie  a  boule.  This  instrument  consists 
of  a  conical  or  acorn-shaped  head  with  a  well-marked  sharp  but  gently- 
rounded  shoulder,  which  is  attached  to  a  flexible  gum-elastic  staff.  (See 
Fig.  23.)  For  the  cases  under  consideration  we  may  need  these  bougies 
a  boule  in  size  ranging  from  18  to  30  French.  For  strictures  we  may 
use  the  smaller  sizes,  which  begin  as  small  as  8  or  10  French. 

Fig.  23. 


Bousrie  a  boule. 


The  technic  of  passing  the  bougie  a  boule  is  as  follows  :  the  penis 
having  been  carefully  cleansed  and  the  patient  being  on  his  back 
the  corona  glan'dis  is  grasped  by  the  thumb  and  forefinger  of  the 
surgeon,  who  holds  the  organ  well  extended  at  right  angles  to  the 
abdominal  walls.  In  the  preliminary  examination  it  is  usually  well 
to  use  rather  small  exploratory  bulbs — namely,  18  or  20  French  scale. 
Having  lubricated  the  instrument  the  surgeon  gently  pushes  it  down 
the  urethra.  As  the  bulb  glides  slowly  along  the  canal  it  may  be 
stopped  for  a  moment  at  any  point,  but  it  is  chiefly  toward  the  peno- 
scrotal angle  as  far  as  the  triangular  ligament  that  morbid  changes  are 
encountered.  If  the  instrument  is  arrested  by  a  morbid  patch  and  does 
not  pass,  a  smaller  one  may  be  employed.  When  the  instrument 
is  thus  introduced  the  surgeon  may  determine,  by  palpating  the  ure- 
thra, the  extent  and  density  of  the  inflammatory  process.  Having 
passed  the  diseased  tissue  the  bulb  may  be  abruptly  stopped  at  the 
triangular  ligament.  As  a  rule,  if  gentle  but  firm  pressure  is  ex- 
erted, the  compressor  urethra?  muscle  relaxes,  and  the  bulb  of  the 
instrument  glides  into  the  bladder.  It  is  then  slowly  withdrawn 
and,  as  the  bulb  passes  outward,  the  condition  of  the  urethra  is  again 
revealed  to  the  surgeon.  In  many  cases  of  chronic  anterior  urethritis 
it  will  be  necessary  to  make  a  second  examination  in  which  larger  bulbs 
are  employed  ranging  from  20  to  30  French.  The  examination  by  the 
larger  bulbs  will  confirm  and  amplify  the  information  gained  in  the  pre- 
liminary one.     Much  can  also  be  learned  of  the  condition  of  the  urethra 


TREATMENT  OF  CHRONIC  GONORRHOEA.  87 

by  passing  a  good-sized  olivary  bougie,  24  to  28  French,  into  the  bladder 
and  then  palpating  the  canal  by  the  finger-tips  as  far  as  accessible.  In 
this  way  any  structural  morbid  changes  may  be  detected. 

Chronic  Urethritis  of  the  Pendulous  Urethra. — Having  ascer- 
tained that  there  is  a  localized  chronic  inflammatory  spot  or  area, 
the  injection  of  a  few  drops  of  nitrate-of-silver  solution,  1  :  1000, 
1  :  500,  or  1  :  250  may  be  given  twice  a  week  or  oftener.  When 
cases  resist  this  treatment,  it  is  well  to  resort  to  the  endoscope  in 
order  to  determine  just  what  condition  exists.  Erosions,  ulcerations, 
granulations,  and  urethral  thickenings  require  circumscribed  applications 
of  solutions  of  nitrate  of  silver  perhaps  as  strong  as  1  :  250,  and  very 
rarely  indeed  stronger — 1  per  cent.  These  applications  should  be  skil- 
fully and  carefully  applied,  in  some  cases  through  the  endoscopic  tube, 
in  others  by  means  of  my  syringe.  The  patient  in  the  intervals  of  treat- 
ment may  use  astringent  injections  with  the  penis-syringe.  When  the 
inflammatory  condition  is  seated  in  the  pendulous  urethra  in  cases  where 
there  is  not  much  hypersemia,  much  benefit  can  be  derived  from  the 
introduction  of  the  straight  steel  sound  and  the  gentle  pressure  or  mas- 
sage of  the  urethral  canal  for  a  few  minutes.  Care  must  be  taken  that 
no  violence  be  done.  In  some  cases  this  procedure  aids  the  nitrate-of- 
silver  injections  in  the  absorption  of  the  effused  cells. 

Chronic  Urethritis  at  Penoscrotal  Angle  and  in  Posterior  Ure- 
thra.— In  some  cases  of  chronic  urethritis  at  the  penoscrotal  angle  and 
of  the  subpubic  curve  in  addition  to  strong  nitrate-of-silver  injections,  the 
introduction  of  olivary  bougies  or  steel  sounds  will  be  required.  In 
these  cases  it  is  well  to  begin  carefully  and  use  at  first  bougies  of  No.  22 
French  scale  once  in  five  or  seven  days.  As  a  rule,  it  is  not  well  at  first 
to  give  the  injection  and  use  the  bougie  at  the  same  seance.  The  size 
of  the  bougie  may  be  gradually  increased,  but  when  a  calibre  of  25  F. 
is  reached  it  is  well  to  use  the  steel  sound.  When  the  case  progresses 
favorably,  it  will  be  found  best  at  most  seances  to  give  an  injection  and 
to  pass  a  sound  at  the  same  time.  The  sensations  of  the  patient  and 
the  condition  of  the  case  will  be  the  determining  criteria  which  will 
guide  the  surgeon.  As  a  rule,  if  the  treatment  is  properly  administered, 
improvement  will  be  apparent  from  the  start  and  the  patient  will  be 
promptly  cured.  (In  this  connection  it  is  well  to  refer  to  the  section 
on  gradual  dilatation  in  the  chapter  on  Stricture  of  the  Urethra.  See 
page  206). 

In  some  rebellious  cases  with  much  thickening  in  the  subpubic  curve 
and  bulbous  urethra  we  may  have  to  resort  to  the  cupped  sound.  Into 
the  depressions  in  this  instrument  nitrate-of-silver  ointment  (5  parts  to 
100  of  lanoline  and  white  wax)  is  introduced.  The  sound  is  then  passed 
and  left  in  place  for  about  five  minutes.     This  treatment  combines  the 


88  TREATMENT  OF  CHRONIC  GONORRHOEA. 

stimulant  effects  of  the  silver  salt  with  gradual  dilatation  and  is  some- 
times very  effective. 

It  is  important  that  dilatation  shall  not  be  commenced  too  early  in 
the  course  of  chronic  urethritis,  since  much  harm  may  be  produced.  As 
a  rule,  a  sound  should  not  be  introduced  into  the  urethra  until  four 
months  after  the  declining  stage  of  gonorrhoea  has  begun. 

Chronic  Follicular  Inflammation. — Inflammation  of  the  urethral 
follicles,  particularly  when  several  inches  down,  is  a  condition  which 
resists  treatment  and  is  difficult  to  handle.  The  parts  must  be  exposed 
by  means  of  the  endoscope,  and  touched  with  a  strong  nitrate-of-silver 
solution  on  cotton  at  the  end  of  a  very  fine  silver  probe,  which,  if 

Fig.  24. 


Cupped  sound. 


possible,  should  be  gently  pushed  into  the  duct.  Some  authors  recom- 
mend the  destruction  of  the  follicle  by  means  of  a  very  minute  galvano- 
cautery  needle.  Great  care  and  circumspection  should  be  used  when 
this  rather  heroic  procedure  is  resorted  to.  After  any  of  these  appli- 
cations it  is  well  to  inject  the  urethra  with  lead-water  twice  a  day. 

Follicular  sinuses  in  the  fossa  navicularis  and  just  within  the  lips  of 
the  meatus  may,  after  thorough  irrigation,  be  injected  with  a  few  drops 
of  silver-nitrate  solution  (1  :  250)  by  means  of  the  hypodermic  syringe, 
the  needle  of  which  is  made  blunt  by  the  removal  of  its  point.  In  sev- 
eral cases  of  juxta-  and  intra-urethral  sinuses  I  have  produced  a  cure  by 
applying  on  a  delicate  silver  probe  a  coating  of  nitrate  of  silver  obtained 
by  melting  the  drug  with  heat.  A  few  grains  of  the  silver  salt  are 
placed  in  a  small  platinum  crucible,  which  is  exposed  to  an  alcohol 
flame  until  liquefaction  occurs ;  then  the  probe  is  dipped  into  the  cru- 
cible and  is  thus  charged. 

CHRONIC   POSTERIOR  URETHRITIS. 

In  the  treatment  of  chronic  posterior  urethritis  with  or  without 
anterior  urethritis  great  care  is  required  to  determine  as  nearly  as  pos- 
sible the  exact  condition  of  aifairs.  In  the  more  recent  cases  we  some- 
times find  some  evidence  of  bladder  incompetence  (the  urine  showing 
no  involvement  of  that  viscus),  which  shows  itself  by  the  escape  of  a 
little  (sij  to  §ss  or  more)  residual  urine  when  the  eye  of  the  catheter 
reaches  the  neck  of  the  bladder.  In  these  rather  early  cases  mild  irri- 
gations of  the  astringents  and  of  permanganate  of  potassa  may  be  used, 


THE    USE   OF  THE  ENDOSCOPE.  89 

and  perhaps  with  benefit.  The  most  uniformly  effective  agent  here 
also  is  the  nitrate  of  silver,  which  may  at  first  be  used  well  diluted, 
1  :  16,000  or  1  :  8000,  in  the  form  of  hot  irrigations.  These  may  result 
in  cure,  but  if  the  result  is  not  perfect,  injections  of  the  same  drug  may 
be  used  in  the  stronger  solutions. 

Posterior  urethritis  combined  with  chronic  prostatitis  and  seminal 
vesiculitis  in  which  there  are  sexual  disability,  premature  ejaculations, 
pollutions,  absence  of  erections,  and  loss  of  sexual  desire,  usually 
requires  the  injection  of  a  few  drops  of  nitrate-of-silver  solutions  1  :  250 
or  1  :  125  every  third,  fourth,  or  fifth  day.  In  these  cases  much  benefit 
often  follows  a  careful  course  of  prostatic,  and  if  possible,  seminal- 
vesicle  massage  (see  sections  on  Chronic  Prostatitis  and  Seminal  Vesicu- 
litis) which  should  not  be  administered  more  frequently  than  once  in 
five,  seven,  or  ten  drops.  Irrigations  of  the  rectum  by  means  of 
Kemp's  tubes  with  very  hot  water  are  sometimes  of  marked  benefit. 

Besides  these  local  measures,  patients  thus  afflicted  need  fresh  air, 
relaxation,  good  sanitary  conditions,  and  attention  should  be  paid  to 
their  sexual  hygiene.  In  some  of  these  cases,  where  there  is  much 
hyperesthesia  of  the  posterior  urethra,  accompanied  by  erotic  symptoms, 
much  benefit  may  be  produced  by  the  introduction  of  steel  sounds  pre- 
viously chilled  with  ice.  This  procedure  should  be  cautiously  carried 
out  and  its  effects  carefully  watched.  It  should  not  be  very  frequently 
adopted,  and  at  the  most  two  seances  a  week  should  be  given,  and  on 
these  days  the  deep  injection  should  be  omitted.  If  good  is  going  to 
follow,  the  patient  will  at  once  speak  of  his  improvement.  Should  it 
produce  a  dull  pain  or  an  uneasy  sensation,  its  use  is  contraindicated. 
It  is  always  well  not  to  use  very  large  sounds  ;  those  having  a  calibre  of 
No.  20  or  22  French  are  the  best. 

The  Use  Of  the  Endoscope. — In  the  treatment  of  chronic  urethritis 
the  endoscope  is  useful  under  certain  sharply-drawn  restrictions.  As  a 
means  of  localizing  an  inflammatory  focus,  of  viewing  surface  appear- 
ances, and  of  allowing  the  use  of  topical  applications  under  free  ocular 
inspection,  it  is  often  of  signal  benefit.  It  is  an  instrument  of  reserve 
rather  than  of  routine,  and  it  always  should  be  used  in  a  rational  and 
conservative  manner.  It  is  to  be  regretted  that  it  has  been  used  very 
much  as  a  toy,  and  has  been  to  some  simply  a  surgical  hobby.  There 
are  those  who  have  been  so  unkind  as  to  say  that  some  surgeons  osten- 
tatiously display  and  use  it  as 'a  means  of  impressing  patients  with  their 
skill  and  science. 

As  a  general  rule,  it  may  be  said  that  when  in  the  treatment  of 
chronic  anterior  urethritis  the  case  resists  the  usual  methods  properly 
applied,  then  it  is  well  to  use  the  endoscope  to  determine  the  exact  seat 
and  nature  of  the  lesion.     It  is  well  to  sound  a  note  of  warning  as  to 


90  TREATMENT  OF  CHRONIC  GONORRHOEA. 

the  inspection  of  the  posterior  urethra.  It  is  safe  to  say  that  many- 
persons  who  cajole  themselves  with  the  idea  that  they  have  inspected 
this  region  have  greatly  deceived  themselves.  It  is  often  very  difficult 
to  efface  the  subpubic  curve  with  the  endoscope  tube,  and  often  much 
damage  is  done  in  the  attempt  or  in  its  accomplishment.  A  skilled 
expert  only  should  make  endoscopic  examinations  of  the  posterior 
urethra. 

The  precipitate  use  of  the  endoscope  at  the  first  examination  of  a 
case,  before  the  other  and  less  radical  methods  o(  examination  have  been 
tried,  is  to  be  very  much  condemned. 

The  efficient  use  of  this  instrument  requires  much  time,  study,  and 
observation.  The  aim  of  the  surgeon  should  always  be  to  use  such  deli- 
cate care  and  circumspection  that  the  operation  is  made  as  little  trouble- 
some and  painful  to  the  patient  as  possible. 

It  is  always  well  to  first  examine  and  familiarize  one's  self  with  the 
appearances  of  the  normal  urethra,  since  by  this  course  the  study  of 
abnormal  conditions  is  rendered  much  easier  and  clearer. 

The  most  useful  endoscope  is  that  invented  by  TV.  K.  Otis. 

The  instrument  consists  of  a  metal  tube  or  cylinder  an  inch  and  a 
quarter  in  length  by  somewhat  less  than  half  an  inch  in  diameter,  the 
first  half  inch  of  which  is  narrowed  conically  forming  a  funnel-shaped 
diaphragm  having  an  opening  a  quarter  of  an  inch  in  diameter,  through 
which  the  rays  of  light  emerge.  At  the  other  end  of  this  tube  is  a  second 
tube  of  the  same  diameter  forming  an  elbow  at  right  angles  to  the  first 
tube  three-quarters  of  an  inch  in  length,  into  which  the  handle  of  the 
instrument  fits. 

The  funnel  portion  unscrews  from  the  upper  tube,  and  a  planoconvex 
lens  at  this  point  concentrates  and  directs  the  rays  of  a  small  electric 
lamp  placed  immediately  behind  it.  This  lens  can  be  readily  removed 
for  cleaning. 

The  handle  consists  of  a  cylindrical  piece  of  hard  rubber  about  one- 
half  inch  in  diameter  and  one  and  a  half  inches  long,  to  the  upper  end 
of  which  is  fixed  the  electric  lamp,  while  the  lower  end  is  arranged  to 
receive  the  cords  leading  the  current  from  the  battery.  A  small  electric 
switch  in  the  form  of  a  milled  wheel  is  placed  on  one  side  of  this  handle, 
a  half  turn  of  which  makes  or  breaks  the  current.  The  two  small  screw- 
heads  seen  on  the  other  side  of  this  handle  serve  the  upper  to  clamp  fast 
the  hood,  the  lower  to  fasten  the  lamp  in  position. 

The  lamp  is  of  a  variety  known  as  "  high  efficiency,"  differing  from 
others  in  a  special  preparation  of  the  filament  which  enables  it  to  give  out  a 
very  intense  light  without  a  corresponding  increase  in  heat ;  it  is  unusually 
strong  and  capable  of  withstanding  a  current  of  from  sixteen  to  twenty 
volts.    It  is  attached  to  a  wire  running  through  the  centre  of  the  handle,  so 


THE  USE  OF  THE  ENDOSCOPE.  91 

that  it  may  be  raised  or  lowered  and  clamped  in  position  by  the  lower  screw 
in  the  handle.  The  only  adjustment  which  may  be  necessary  is,  when 
changing  the  lamp,  to  see  that  the  filament  of  the  new  lamp  should  come 
exactly  opposite  the  centre  of  the  lens.  A  small  piece  of  brass  with  a 
pinhole  in  it  has  been  placed  on  the  handle  behind  the  lamp  socket,  so 
that  by  holding  this  to  the  light  and  moving  the  lamp  up  or  down  until 
the  filament  is  exactly  across  the  centre  of  the  hole,  the  lamp  may  be 
clamped  in  the  correct  position. 

A  strong  wire  connects  the  instrument  to  the  urethroscopic  tube  by 
means  of  a  simple  joint. 

With  reference  to  the  length  of  the  handle  and  the  weight  of  the 
instrument,  both  of  which  have  been  criticized  favorably  and  adversely, 
I  would  say  that  these  depend  entirely  on  the  whim  of  the  operator,  as 
the  handle  may  be  lengthened  to  any  extent  or  entirely  obviated,  while 
by  slight  alteration  in  material  and  construction  the  weight  (less  than 
one  ounce)  may  be  reduced  to  a  few  grains. 

The  accompanying  illustration  is  from  a  photographic  reproduction 
exactly  half  the  size  of  the  original.     A  straight  line  drawn  along  the 

Fig.  25. 


W.  K.  Otis  "  perfected  "  endoscope. 

lower  edge  of  the  urethroscopic  tube  through  the  illuminating  apparatus 
will  give  a  very  practical  illustration  of  how  little  is  the  interference 
with  a  direct  view  of  the  field  or  the  introduction  of  instruments.  (See 
Fig.  25.) 

Great  pains  have  been  taken  and  many  experiments  made  to  perfect 
this  instrument  with  the  result :  Of  obtaining  an  illumination  of  field 
such  as  is  not  found  in  any  other  of  any  type.  It  gives  the  entire  field 
of  the  tube  used,  offers  no  obstruction  to  the  use  of  applicators,  and  at  the 


92  TREATMENT  OF  CHRONIC  GOSORRHCEA. 

same  time  nothing  is  inserted  into  the  urethra  which  cannot  be  rendered 
thoroughly  aseptic  by  boiling.  It  is  simple  in  construction,  strong,  inex- 
pensive, and  jnlfils  all  the  indications  of  a  good,  practical,  working  instru- 
ment. 

The  instrument  is  attached  to  the  Ivlotz  nrethroscopic  tube  bv  means 
of  a  stout  wire  an  inch  and  a  half  in  length,  with  hinged  joints  at 
each  end,  which  swing  in  opposite  directions  and  are  furnished  with 
set  screws,  thus  allowing  the  instrument  to  be  put  in  any  position, 
though  when  once  adjusted  it  will  rarely  be  necessary  to  move  it. 

The  patient  having  urinated  is  placed  on  his  back  with  the  buttocks 
resting  on  the  edge  of  the  operating-table,  his  feet  being  properly  sup- 
ported. The  endoscopic  tube  is  lubricated  and  passed  slowly  into  the 
urethra  as  far  as  the  bulb.  The  obturator  is  withdrawn  and  the  light 
turned  on.  By  gently  withdrawing  the  tube  the  whole  anterior  urethra 
may  be  clearly  examined.     All  morbid  conditions  are  then  noted. 

The  applications  suitable  for  endoscopic  treatment  are,  in  the  main, 
solutions  of  nitrate  of  silver,  5  :  10  to  100  of  water.  These  should  be 
applied  by  means  of  swab-holders  or  applicators  carrying  a  tuft  of 
absorbent  cotton  moistened  in  the  medicated  fluid.  Strong  solutions 
of  sulphate  of  copper,  5  :  20  to  100,  may  be  used,  and  in  some  cases  such 
severe  remedies  as  solution  of  perchloride  of  iron,  liquor  hydrargyri 
pernitratis,  or  Lugol's  solution,  may,  of  necessity,  be  resorted  to.  These 
latter  solutions  should  always  be  applied  sparingly  and  only  on  the 
morbid  surfaces.  Papillomatous  urethritis  may  require  operative  meas- 
ures if  the  little  growths  cannot  be  scooped  off  with  the  end  of  the 
endoscopic  tube.  They,  with  polypoid  growths,  may  sometimes  be 
removed  by  tampon  ecrasement,  which  means  the  introduction  of  a 
plug  of  cotton  on  the  end  of  an  applicator,  which  is  pushed  forward 
and  backward  and  rotated  from  side  to  side  until  the  growth  is  detached. 
After  this  a  strong  nitrate-of-silver  application  should  be  made.  In 
some  cases  the  urethral-polypus  forceps  may  be  employed. 

The  Question  of  the  Infectiousness  of  Chronic  Urethral 
Suppurations. 
The  question  of  the  infectiousness  of  the  secretion  of  chronic  gonor- 
rhea is  one  which  frequently  arises,  and  concerning  which  we  have  no 
precise  data.  In  order  to  treat  the  subject  intelligently  we  must  study 
the  peculiarities  of  each  case  and  be  guided  by  the  results  obtained.  It 
will  not  suffice  to  state  generalities  merely,  or  to  harp  on  the  persistence 
of  the  presence  of  the  gonococcus,  or  to  endeavor  to  draw  conclusions 
from  statistics.  We  know  by  experience  that  in  the  third  to  the  sixth 
month  after  the  decline  of  a  case  of  gonorrhoea  in  many  patients  a  still 
infecting  pus  may  be  found  in  the  urethra.     In  many  other  cases  no 


INFECTIOUSNESS  OF  CHRONIC   URETHRAL  SUPPURATIONS.     93 

such  pus  can  be  found  a  month  or  two  after  the  cure  of  gonorrhoea.  It 
follows,  therefore,  that  there  is  danger  of  contamination  of  women,  in 
many  cases,  by  men  who  were  seemingly  cured  of  gonorrhoea  six  months 
previously.  Consequently,  we  must  be  on  our  guard  when  men  having 
within  half  a  year  only  recovered  from  gonorrhoea  ask  our  opinion  as 
to  the  propriety  of  marriage.  In  such  cases  the  urine,  particularly  that 
of  the  early  morning,  should  be  carefully  examined.  If  pus-cells  are 
still  present,  together  with  epithelial  cells,  the  patient  should  be  sub- 
jected to  further  treatment,  even  though  the  gonococcus  cannot  be  dis- 
covered in  the  microscopic  field.  In  these  chronic  cases  the  examination 
should  be  pushed  further  and  the  condition  of  the  prostate  and  seminal 
vesicles  should  be  definitely  ascertained.  All  morbid  secretions  from 
these  parts  should  be  carefully  examined  under  the  microscope. 

My  own  experience  convinces  me  that,  in  general,  after  the  lapse  of 
six  months  from  the  time  of  cure,  provided  there  has  been  no  recur- 
rence, it  is  safe  for  a  man  to  marry.  It  is  a  matter  of  common 
experience  to  see  men  who  have  only  one  or  two  months  before 
recovered  from  gonorrhoea  have  intercourse  with  various  healthy  women 
with  absolute  safety  to  the  latter.  Though  we  can  thus  speak  positively 
concerning  these  cases  where  men  do  as  they  please,  we  must  be  guarded 
when  we  are  called  upon  for  an  opinion  and  do  our  utmost  to  protect 
the  innocent.  There  can  be  no  doubt  that  many  women  escape  infec- 
tion by  men  recently  recovered  from  gonorrhoea  by  reason  of  the  fact 
that  the  secretion  is  small  in  amount  and  is  washed  out  of  the  urethra 
in  urination. 

I  am  so  constantly  seeing  men  who  have  chronic  anterior  and  poste- 
rior urethritis,  who  have  intercourse  over  long  periods  with  women, 
wives  and  mistresses,  without  communicating  gonorrhoea  to  them,  that 
I  am  led  to  the  belief  that  in  very  many  of  these  cases  the  pus  is 
inactive  or  effete.  In  such  cases  the  microscope  often  shows  a  field 
covered  with  small  withered  pus-cells,  and  large,  flabby  epithelial  cells 
studded  with  small  fat-globules.  When  I  see  these  features  I  am 
generally  pretty  certain  that  the  secretion  is  not  liable  to  cause  infection. 
Exacerbations  of  such  a  low  grade  of  morbid  process  may,  however, 
produce  a  pus  competent  to  infect. 

I  think  it  may  be  stated  without  fear  of  contradiction  that  if  the 
vast  number  of  cases  of  chronic  suppuration  of  the  urethra  which  are 
known  to  exist  in  men  gave  issue  to  infecting  pus,  gonorrhoea  in  women 
would  be  as  common  as  it  is  in  men.  This  certainly  is  not  the  case, 
for  there  are  at  the  very  least  thirty  cases  of  gonorrhoea  in  men  to  one 
case  in  women.     This  is  under-  rather  than  over-stated. 

To  sum  up,  we  may  say,  on  general  principles,  that  clanger  lurks  in 
all  forms  of  urethral  pus,  particularly  in  that  which  is  found  within  six 


94  TREATMENT  OF  CHRONIC  GONORRHOEA. 

months  after  the  supposed  cure  of  gonorrhoea.  In  older  cases  it  may 
be  dangerous,  but  daily  experience  shows  us  that  for  some  reason  or 
other  women  may  with  impunity  cohabit  with  men  whose  urethrse 
secrete  pus  sparingly.  In  many  cases  personal  cleanliness  and  the 
salutary  effects  of  urination  may  be  the  underlying  causes  of  this 
immunity.  In  this  connection  it  is  well  to  repeat  what  has  already 
been  said.  Too  much  stress  is  laid  by  some  authors  upon  gonococci 
and  other  microbes  in  chronic  urethritis.  In  very  many  cases  the 
gonococcus  has  produced  its  pathological  results  and  has  disappeared, 
leaving  an  inflammation  of  the  vessels  and  cell-infiltration  behind  it, 
which  is  then  uninfluenced  by  microbes.  This  smouldering  inflamma- 
tory patch  gives  forth  pus  which  may  not  contain  microbes ;  hence  it 
produces  no  bad  result.  This  phoenix-like  character  given  by  many 
to  the  gonococcus  is  in  most  cases  a  myth. 


CHAPTER  VII. 

GONORRHOEA  OF  THE  RECTUM  AND  MOUTH. 

It  is  now  a  well-established  fact  that  the  rectum  may  be  attacked  by 
the  gonorrhoeal  process.  This  affection  is  more  or  less  frequently 
observed  in  countries  in  which  sodomy  is  practised,  and  it  sometimes 
occurs  in  America. 

Symptoms. — The  first  symptom  of  gonorrhoea  of  the  rectum  is  an 
uneasy  sensation,  attended  with  more  or  less  heat.  This  may  be  com- 
plained of  within  from  two  to  ten  days  after  contamination.  Heat  and 
burning  increase,  defecation  becomes  painful  and  often  more  frequent, 
and  soon  a  discharge  is  noticed  which  may  at  first  be  watery  or  milky, 
but  which  promptly  becomes  purulent  and  even  streaked  or  mixed  with 
blood.  At  this  time  burning  heat  and  itching  are  felt  in  the  anus, 
which  becomes  red  and  swollen,  and  a  deep  dull,  aching  pain  in  the  rec- 
tum is  felt.  Defecation  becomes  more  and  more  painful,  and  sometimes 
is  so  severe  as  to  be  agonizing.  Frequent  calls  to  stool  keep  the  patient 
in  a  condition  of  apprehension  and  suffering.  The  purulent  and  bloody 
secretions  often  become  offensive  in  smell,  and  ooze  constantly  from  the 
inflamed  and  relaxed  anal  orifice.  In  well-marked  cases  decided  consti- 
tutional reaction  is  observed  at  the  end  of  a  few  days  or  a  week.  The 
patient  looks  haggard  and  worried,  there  is  some  rise  in  temperature,  the 
pulse  is  rapid  and  small,  and  general  malaise  and  debility  are  experienced. 

The  objective  symptoms  of  gonorrhoea  of  the  rectum  and  anus  are 
striking.  The  mucous  membrane  becomes  red  and  swollen,  and  in 
patches  excoriated  and  ulcerated,  with  here  and  there  red  mammillations 
corresponding  to  inflamed  follicles  ;  a  foul,  tenacious  pus  bathes  the  rec- 
tal walls  and  escapes  from  the  anal  ring,  which  is  thickened,  reddened, 
excoriated,  and  perhaps  the  seat  of  several  small-  or  good-sized  fissures. 

Etiology. — In  most  of  the  cases  the  infection  occurs  as  the  result  of 
sodomy,  more  frequently  in  women  and  young  boys,  but  also  in  older 
males,  the  active  agent  suffering  at  the  time  from  gonorrhoea.  In  some 
cases  the  gonorrhoeal  pus  is  carried  to  the  rectum  by  means  of  a  soiled 
finger.  It  is  claimed  that  in  acute  gonorrhoea  in  women  the  pus,  escaping 
from  the  genitals,  may  infect  the  anus  and  rectum.  This  accident  is,  of 
course,  possible,  but  as  a  broad  general  rule  it  may  be  stated  that  rectal 
gonorrhoea  results  from  the  intromission  of  an  organ  secreting  or  soiled 
with  virulent  pus. 

95 


96  GONORRHCEA   OF  THE  RECTUM  AND  MOUTH. 

Diagnosis. — It  is  frequently  difficult  to  determine  positively  the 
gonorrheal  nature  of  a  suppurating  rectal  inflammation.  In  some  cases 
the  history  or  concomitant  circumstances  point  to  a  gonorrheal  origin. 
Very  many  patients  will,  from  motives  of  shame,  deny  any  unnatural 
practice  and  will  endeavor  in  every  way  to  mislead  the  physician. 
Others,  again,  will,  with  barefaced  candor,  promptly  admit  the  shameful 
mode  of  origin  of  their  trouble.  In  women  suffering  synchronously 
from  purulent  discharge  from  the  vagina,  urethra,  or  vulva  the  diagnosis 
is  often  easy.  As  a  rule,  the  severity  and  persistency  of  a  rectal  or  anal 
suppurating  process  will  excite  the  suspicions  of  the  physician.  Then, 
again,  the  sudden  onset  and  quick  development  of  rectal  gonorrhoea  (the 
facts  of  which  can  generally  be  obtained  without  difficulty  from  the 
patient)*  will  be  an  aid  in  determining  the  nature  of  the  affection. 

In  many  cases  a  diagnosis  can  be  readily  made  by  the  microscopic 
examination  of  the  pus,  which  must  be  taken  on  a  sterilized  platinum- 
wire  loop  from  the  surface  most  actively  inflamed.  To  this  end  a  specu- 
lum must  be  passed  into  the  anus  or  rectum,  as  the  case  may  be.  Pus 
which  has  escaped  from  the  anal  orifice  is  liable  to  be  mixed  with  other 
forms  of  cocci ;  therefore  it  should  never  be  used.  In  the  early  stages 
of  an  acute  process  there  will  usually  be  little  difficulty  in  finding  speci- 
mens of  pus  in  which  there  are  gonococci. 

Prognosis. — Though  the  course  of  this  affection  is  often  severe  and 
sometimes  alarming,  its  tendency  in  healthy  and  cleanly  persons  is 
toward  recovery. 

Treatment. — The  patient  should  be  confined  to  the  house  and  placed 
in  a  recumbent  position.  Warm  sitz-baths  should  be  taken,  and  the 
rectum  should  be  freely  injected  several  times  a  day  with  a  saturated 
boric  solution,  warm  or  cold  according  as  it  is  agreeable  to  the  patient. 
Enemata,  hot  or  cold,  of  lead  and  opium  are  sometimes  very  soothing 
and  efficacious.  Lead-water  or  boric  solution  in  combination  are  also 
of  much  benefit.  It  is  necessary  to  free  the  bowel  of  fasces,  and  for  this 
purpose  castor  oil  or  Epsom  salts  may  be  given.  In  the  intervals  of 
defecation  suppositories  of  morphine  or  opium,  sometimes  with  iodo- 
form, may  be  used  if  necessary.  When  the  intensity  of  the  symptoms 
has  passed,  slightly  stimulating  enemata  of  sulphate  of  zinc  and  lauda- 
num may  be  used.  Solutions  of  bichloride  of  mercury  have  not  proved 
of  value  as  injections.  Toward  the  cessation  of  the  suppurating  process 
solutions  of  nitrate  of  silver  (1  :  8000  or  1  :4000)  may  be  very  useful. 
To  these  solutions  wine  of  opium  or  fluid  extract  of  belladonna  may  be 
added. 

Gonorrhoea  limited  to  the  region  of  the  anal  orifice  requires  constant 
attention  to  cleanliness  and  sitz-baths,  and  the  application  (when  acute) 
of  lead-and-opium  wash,  and,  later,  of  bland  dusting  powders. 


GONOBRHCEA    OF  THE  MOUTH.  97 

GONORRHOEA  OF   THE  MOUTH. 

Our  knowledge  of  gonorrhoeal  infection  of  the  mouth  is  very  incom- 
plete, and  further  observation  and  careful  clinical  and  bacteriological 
studies  are  necessary  before  a  satisfactory  account  can  be  given  of  it.  A 
study  of  the  cases  thus  far  reported  warrants  the  assumption  that  there 
is  a  specific  inflammation  of  the  mouth  contracted  by  beastly  and  unnatural 
practices,  and  perhaps  caused  by  the  gonococcus.  From  the  following 
cases  an  idea  of  the  clinical  history  of  this  affection  may  be  obtained  : 

Holder  relates  the  case  of  a  young  man  who  had  buccal  coitus 
with  a  man  suffering  from  urethral  gonorrhoea.  The  day  after  he  had 
pain  in  the  lips  and  gums.  On  the  fourth  day  the  mucous  membrane 
of  the  lips  and  buccal  cavity  became  intensely  red,  the  gums  were  spongy 
and  inclined  to  bleed,  with  a  tendency  to  recede  from  the  teeth,  and  the 
buccal  secretion  was  increased  in  quantity.  Motion  of  the  mouth  was 
painful.  Holder  states  that  the  affection  begins  with  a  sensation  of 
heat  and  dryness  in  the  mouth,  which  at  first  appears  very  red.  Soon 
a  purulent  secretion  flows  from  the  swollen  and  inflamed  parts,  which 
may  be  covered  with  an  aphthous-like  exudation.  The  affection  in  this 
case  was  cured  by  an  alum  gargle  in  eight  days. 

Cutler  also  reports  a  case  which  is  fully  as  striking  as  the  foregoing. 
It  was  that  of  a  woman  who  had  coitus  ab  ore  with  a  sailor  who  was 
found  to  be  suffering  from  gonorrhoea  ;  the  next  morning  her  mouth  was 
raw  and  sore  and  the  saliva  had  a  horrible  taste.  On  the  second  day 
little  sores  appeared  on  the  lips,  and  on  the  third  day  the  gums  and 
tongue  became  swollen  and  painful.  By  the  fifth  day  the  whole  buccal 
cavity  was  so  inflamed  that  she  could  not  eat,  and  a  whitish  fluid,  mixed 
with  blood,  having  an  unpleasant  odor  and  taste,  was  secreted.  Ex- 
amination showed  the  mucous  membrane  of  the  lips  and  cheeks  was 
thickened,  reddened,  denuded  of  epithelium  in  spots,  and  covered  in 
areas  with  a  false  membrane,  which  was  readily  detached,  leaving  an 
excoriated  surface.  The  gums  were  swollen,  retracted  from  the  teeth, 
and  bled  readily  on  pressure.  The  tongue  was  swollen  and  very  tender, 
and  could  only  be  slightly  protruded,  and  then  only  Math  much  effort 
and  pain.  The  surface  was  red  and  glazed  and  covered  with  small 
ulcers  which  secreted  a  thick  yellow  pus.  The  soft  palate  and  pillars 
of  the  fauces  were  much  inflamed,  but  the  parts  beyond  were  in  a  normal 
condition.     The  breath  was  very  offensive.     There  was  little  salivation. 

The  mouth-secretion  consisted  of  mucus,  pus-cells,  and  epithelium, 
and  contained  a  large  quantity  of  bacteria.  In  the  false  membrane 
a  micro-organism  resembling  the  gonococcus  was  seen,  but  its  identity 
was  not  fully  established.  Soothing  applications  brought  about  an 
amelioration  of  the  symptoms. 
7 


CHAPTER  VIII. 

COMPLICATIONS  OF  GONORRHOEA. 

CONGESTION  OF  THE  PROSTATE. 

Acute  congestion  of  the  prostate  may  occur  in  the  course  of  acute 
posterior  urethritis  either  in  its  declining  or  terminal  stage. 

Symptoms. — With  this  further  extension  of  the  gonorrheal  process 
the  patient  has  still  other  symptoms,  besides  those  of  acute  posterior 
urethritis.  He  complains  of  a  sensation  of  dull  weight  and  pressure  in 
the  perineum  deep  in  the  pelvis,  and  an  uneasy  sense  of  fulness  in  the 
rectum  or  anus.  In  severe  cases  rectal  tenesmus  may  add  to  the  patient's 
discomfort.  The  vesical  tenesmus  may  be  increased,  and  often  in  defe- 
cation the  patient  experiences  severe  pain  in  the  prostate  when  the  fecal 
mass  passes  under  it.  When  there  is  much  swelling,  the  stools  are  small 
and  ribbon-shaped.  Rectal  examination  reveals  a  swollen  organ,  firm 
or  boggy,  hot  and  very  painful,  broader  than  normal  from  side  to  side, 
and  bulging  considerably  into  the  rectum. 

Painful  erections  and  bloody  pollutions  are  sometimes  very  dis- 
tressing symptoms. 

In  some  cases  the  patient  experiences  difficulty  in  urination,  and 
complains  of  a  sensation  as  if  his  urethra  was  too  small  to  allow  the 
stream  to  pass  through  it  even  with  great  straining.  Under  these  cir- 
cumstances, the  stream  is  small  and  weak,  even  hesitating  and  inter- 
mittent. In  some  cases,  such  is  the  swollen  condition  of  the  organ  and 
of  its  urethral  mucous  lining  that  the  patient  cannot  void  his  urine,  and 
has  to  be  relieved  by  the  introduction  of  the  catheter.  In  bad  cases 
there  may  be  vesical  and  rectal  tenesmus  superadded,  and  in  some  cases 
there  is  spasm  of  the  compressor  urethrse  muscle.  Under  these  circum- 
stances the  patient  often  fails  to  thoroughly  empty  his  bladder,  and  then 
the  accumulation  of  urine  causes  continuous  vesical  tenesmus.  The 
bowels  are  frequently  constipated,  and  when  the  vesical  tenesmus  comes 
on  the  patient  makes  painful  and  often  vain  efforts  to  free  them. 

Examination  of  the  urine  gives  the  same  results  as  are  seen  in  acute 
posterior  urethritis. 

In  the  great  majority  of  cases  this  congestion  is  temporary.  It  may 
last  a  few  days  or  two  or  three  weeks ;  usually,  however,  resolution 
takes  place  in  about  ten  days.  With  the  decline  of  the  posterior  ureth- 
ritis the  swelling  and  tenderness  usually  subside.     In  some  cases  the 

98 


SUBACUTE  AND  CHRONIC  CONGESTION  OF  THE  PROSTATE.    99 

involution  of  this  congested  condition  of  the  process  occurs  suddenly 
and  unexpectedly  a  few  days  after  its  onset. 

In  exceptionally  bad  cases  the  inflammation  becomes  so  severe  that 
an  abscess  is  developed. 

Subacute  and  Chronic  Congestion. — A  subacute  congestion  of  the 
prostate  may  be  due  to  violence  from  sounds,  catheters,  lithotrity  instru- 
ments, to  the  irritation  of  a  stone  in  the  bladder  and  of  a  fragment  of 
stone,  or  of  small  stones  impacted  in  its  mucous  membrane,  and  to  stric- 
ture. Recently  many  cases  of  subacute  prostatitis  have  been  observed 
as  a  result  of  the  intemperate  methods  of  treatment  now  so  much  in 
vogue  which  are  intended  to  abort  or  quickly  cure  gonorrhoea. 

In  chronic  posterior  urethritis  subacute  congestion  of  the  prostate 
may  be  caused  by  sexual  and  alcoholic  excesses,  by  masturbation,  and 
by  violent  exercise,  particularly  in  horseback  riding  and  bicycling. 

In  some  rather  rare  cases  rectal  examination  shows  that  certain  parts 
of  the  prostate  are  more  swollen  and  harder  than  the  rest.  In  this  con- 
dition it  may  be  that  certain  groups  of  follicles  are  the  seats  of  greater 
oedematous  hyperplasia  than  the  balance  of  the  tissue. 

Treatment. — When,  during  gonorrhoea,  symptoms  of  congestion  of 
the  prostate  are  observed,  the  patient  should  at  once  be  put  to  bed  and 
treated  on  antiphlogistic  principles.  The  bowels  should  be  kept  free 
and  the  diet  should  be  of  gruel  or  bread  and  milk.  In  the  case  of 
strong  individuals  six  or  more  leeches  may  be  applied  just  in  front  of 
the  anus,  and  the  patient  be  then  put  in  a  hot  sitz-bath.  No  general  rule 
can  be  laid  down  as  to  the  use  of  heat  or  cold.  In  some  cases  heat  gives 
marked  relief,  and  in  others  cold  acts  equally  as  beneficially.  Hot  flax- 
seed poultices  or  the  hot-water  bag,  with  the  intervention  of  some  lint 
well  moistened  with  water,  may  be  applied  to  the  perineum.  In  these 
cases  very  warm  enemata,  given  by  means  of  Kemp's  rectal  irrigator, 
act  well  on  the  prostate  and  free  the  rectum  of  feces.  In  case  cold  is 
more  grateful,  an  India-rubber  bag  filled  with  ice-water  or  broken  ice 
may  be  applied  to  the  perineum,  on  which  a  folded  towel  must  be  placed 
so  that  the  intensity  of  the  cold  may  be  moderated  to  suit  the  patient's 
feelings,  or  irrigations  with  cold  water  may  be  cautiously  used. 

All  urethral  injections  being  suspended,  the  patient  may  take  the 
potassa  and  hyoscyamus  mixture  (see  page  60),  and  drink  freely  of 
diluent  waters  of  various  kinds,  according  to  the  preference  of  the  sur- 
geon. Morphine  or  opium  should  be  given  generously,  if  necessary,  by 
the  mouth  or  in  the  form  of  suppository  in  order  to  relieve  pain. 

When  the  patient  is  up  and  around  again  he  may  be  much  benefited 
by  lavages  of  a  very  mild  solution  of  nitrate  of  silver,  1  :  8000  or 
1  :  4000,  which  should  be  given  every  second  day,  and  every  day  if 
well  borne  and  beneficial. 


100  COMPLICATIONS  OF  GONORRHOEA. 

If  during  the  course  of  congestion  of  the  prostate  complete  retention 
of  urine  occurs,  it  should  be  relieved  by  careful  catheterization.  For 
this  purpose  an  aseptic  silk  or  lisle-thread  catheter  (which  is  both  flexi- 
ble and  at  the  same  time  firm  and  very  smooth),  of  a  calibre  of  not  more 
than  12  or  13  French  scale,  should  be  introduced  into  the  bladder. 

For  the  treatment  of  subacute  and  chronic  congestion  of  the  pros- 
tate, the  measures  recommended  for  the  treatment  of  chronic  posterior 
urethritis  (see  page  83,  et  seq.)  should  be  adopted  in  combination  with 
careful  massage  of  the  organ. 

Abscess  of  the  Prostate. 

In  some  rare  cases  of  acute  gonorrhoeal  congestion  of  the  prostate 
the  inflammatory  process  becomes  so  severe  that  an  abscess  is  formed. 

Symptoms. — The  formation  of  pus  in  the  prostate  is  usually  attended 
by  quite  well-marked  symptoms,  such  as  chills,  fever,  general  depression, 
a  sensation  of  throbbing  in  that  body,  and  a  feeling  as  if  there  was  a 
lump  in  the  rectum.  There  may  also  be  pain  along  the  urethra  in  the 
perineum,  rectum,  and  lumbar  region.  The  further  symptoms  are 
painful  micturition  and  defecation.  In  some  cases  the  urethral  canal 
is  entirely  occluded  by  the  swelling,  and  the  patient  is  unable  to  pass 
any  of  his  urine.  He  of  necessity  lies  on  his  back  and  flexes  his 
thighs,  thereby  avoiding  all  pressure  on  the  perineum. 

As  a  rule,  however,  when  the  abscess  is  fully  formed,  the  constitu- 
tional symptoms  are  much  more  pronounced  than  at  first.  The  rigors 
are  more  severe  and  are  attended  with  flashes  of  heat ;  there  are  great 
thirst,  restlessness,  and  jactitation,  very  high  fever,  and  sometimes 
delirium.  The  pain  becomes  more  violent  and  the  throbbing  more 
distressing,  and  the  sensation  of  fulness  and  weight  at  the  neck  of  the 
bladder  and  in  the  rectum  and  anus  causes  agony.  These  symptoms, 
together  with  the  frequent  scalding  urination,  made  drop  by  drop  or  in 
a  thin,  feeble  stream,  stamp  abscess  of  the  prostate  as  one  of  the  most 
acutely  painful  and  distressing  maladies  known  to  man. 

With  the  bursting  of  the  abscess,  naturally  or  by  operation,  every- 
thing is  changed.  The  patient  is  immediately  relieved  of  his  suffering, 
he  can  urinate  freely,  and  his  febrile  symptoms  soon  disappear.  If  the 
inflamed  tissues  contract  and  efface  the  abscess-cavity,  as  they  commonly 
do,  all  is  well  and  the  patient  is  spared  further  trouble. 

It  must  be  remembered,  however,  that  there  are  many  cases  of  pros- 
tatic abscess  in  which  the  symptoms  are  not  by  any  means  as  severe  as 
just  described,  and  in  which  the  patient  is  not  confined  to  his  bed. 

Course. — Abscess  of  the  prostate  always  begins  in  one  or  more 
follicles,  which  become  acutely  inflamed.  From  this  focus  the  morbid 
process  increases  and  forms  abscesses  of  various  sizes.     As  a  rule,  the 


ABSCESS  OF  THE  PROSTATE.  101 

lateral  lobes  are  more  frequently  the  seat  of  abscess  than  the  third 
portion.  There  may  be  one  or  two  abscesses,  and  in  exceptional  cases 
there  may  be  as  many  as  from  six  to  twenty.  In  this  event  as  many 
different  follicles  have  become  the  seat  of  abscess  as  there  are  abscesses, 
which  are  usually  of  the  size  of  a  pea  and  even  smaller.  When  the 
abscess  is  limited  to  one  lobe  and  points  toward  the  urethral  canal,  it 
may  partly  or  wholly  block  it  up.  The  introduction  of  a  catheter  then 
to  relieve  retention  will  be  accomplished  with  more  or  less  difficulty, 
and  its  point  will  deviate  in  the  opposite  direction  from  the  lobe 
involved.  Rectal  examination  will  reveal  general  enlargement  of  the 
organ,  and  it  may  happen  that  the  surgeon  will  be  able  to  ascertain  that 
the  process  is  unilateral. 

The  size  of  these  abscesses  varies  considerably.  They  may  contain 
a  teaspoonful,  an  ounce,  and  even  as  much  as  eight  ounces,  of  pus. 
The  contents  of  these  abscesses  may  be  pure  pus  free  from  odor,  or  it 
may  be  serosanguinolent ;  it  may  be  mixed  with  the  debris  of  the 
gland  or  it  may  be  of  a  very  unhealthy  character  and  very  fetid. 

Abscesses  superficially  seated  in  the  prostate  and  pointed  toward  the 
urethra  cannot,  as  a  rule,  be  clearly  defined  by  rectal  examination,  but 
their  presence  may  be  detected  by  the  passage  of  a  catheter  of  medium 
stiffness.  When  the  abscess  is  deeply  seated  in  the  prostate,  it  can 
generally  be  well  made  out  by  the  finger  in  the  rectum. 

Abscess  of  the  prostate  may  also  form  in  an  insidious  manner,  with- 
out provoking  any  general  or  local  symptoms  pointing  to  its  existence. 

In  rather  more  than  one-half  of  the  cases  the  abscess  bursts  into  the 
urethra,  and  it  is  safe  to  say  that  at  least  a  large  majority  of  the  patients 
experience  no  ulterior  trouble. 

Unfortunately,  however,  prostatic  abscesses  may  open  into  the  bladder, 
the  rectum,  the  vesicorectal  space,  the  perineum,  and  the  peritoneal  cavity. 

When  the  abscess  is  developed  in  the  posterior  portion  of  the  gland 
the  tendency  is  for  it  to  burst  into  the  rectum,  which  is  a  serious  con- 
dition. It  then  leaves  a  fistulous  tract  which  it  is  very  difficult  to  heal, 
and  which  allows  the  escape  of  urine  into  the  rectum.  The  pus,  how- 
ever, may  burrow  downward  and  point  as  a  red  indurated  area  in  the 
perineum  anterior  to  the  anal  orifice.  It  may  pass  through  the  ischio- 
rectal fossa  and  appear  in  the  perineum.  It  may  extend  toward  the 
scrotum  and  sheath  of  the  penis,  and  may  pass  down  to  the  thigh  or 
upward  to  the  region  of  the  false  ribs. 

The  other  modes  of  burrowing  are  quite  rare,  and  each  of  them  pre- 
sents its  individual  indications  for  surgical  relief. 

In  the  course  of  these  aberrant  burrowings  many  complications  may 
occur,  and  there  is  always  danger  of  pysemia. 

The  bursting  of  the  abscess  into  the  peritoneum  always  causes  great 


102  COMPLICATIONS  OF  GONORRHOEA. 

pelvic  pain  and  very  severe,  even  alarming,  constitutional  symptoms. 
Death  usually  ensues  in  a  day  or  two. 

In  the  progress  of  the  burrowing  process  the  patient  may  experience 
more  or  less  pain  in  the  parts,  which  become  red,  swollen,  and  hard. 

Congestion  and  abscess  of  the  prostate  are  generally  found  in  young 
men. 

Prognosis. — Abscess  of  the  prostate  is  almost  always  a  painful 
affection,  and  sometimes  a  dangerous  and  even  deadly  one.  In  quite 
rare  cases  the  abscess  when  not  recognized  and  untreated  causes  pyaemia 
and  death.  The  rectal  fistulas  are  very  hard  to  cure,  and  they  cause 
much  discomfort  and  suffering  to  the  patient. 

When  the  patient  is  young,  otherwise  healthy,  and  of  firm  fibre  and 
of  good  habits,  his  chances  of  recovery,  even  when  afflicted  with  bad 
fistulse,  are  usually  good.  In  elderly  and  sickly  individuals  the  prog- 
nosis is  usually  grave. 

With  the  institution  of  prompt  aseptic  surgical  intervention  in 
cases  of  abscess  of  the  prostate  the  prognosis  becomes  very  much  more 
favorable. 

Treatment. — The  treatment  of  abscess  of  the  prostate  should  be 
based  on  general  surgical  principles.  The  first  essential  is  to  deter- 
mine, if  possible,  in  which  direction  the  abscess  points.  If  the  inflam- 
matory swelling  is  superficial  and  pushes  into  the  urethra,  the  surgeon 
will  very  often  have  timely  warning  by  reason  of  the  difficulty,  and 
even  impossibility,  of  urination  which  the  patient  experiences.  In 
such  cases  the  catheter  must  of  necessity  be  used,  and  fortunately  it 
very  often  causes  the  abscess  to  open  and  discharge  into  the  urethra  in 
which  event  prompt  resolution  occurs.  When  the  abscess  is  deeply 
seated,  active  and  early  surgical  intervention  must  be  employed  in  the 
following  manner  :  the  patient,  being  prepared  and  etherized,  is  placed 
in  the  lithotomy  position,  with  the  thighs  widely  separated,  then  the 
abscess-cavity  is  opened  by  means  of  a  long  incision  in  the  perineum 
just  in  front  of  the  anus.  In  making  the  dissection  the  surgeon  is 
much  aided  by  having  the  left  index  finger-tip  in  the  rectum  at  the 
apex  of  the  prostate  and  by  the  presence  of  a  sound  or  bougie  in  the 
urethra.  The  wound  is  then  irrigated,  packed,  and  dressed  in  the 
usual  manner. 

Gonorrhoeal  inflammation  of  the  prostate  may  be  one  of  the  pre- 
disposing causes  of  chronic  prostatitis,  all  forms  of  which  are  described 
on  page  288,  et  seq. 

URETHROCYSTITIS. 

Until  within  the  past  few  years  posterior  urethritis,  acute  and  chronic, 
was  described  as  cystitis,  which  was  said  to  be  a  frequent  complication 


ACUTE  UBETHRO-CYSTITIS.  103 

of  gonorrhoea.  To-day  we  have  very  clear  ideas  as  to  the  nature  and 
course  of  posterior  urethritis,  acute  and  chronic  (see  sections  on  these 
subjects),  and  we  know  positively  that  in  very  many  cases  of  these  trou- 
bles there  is  no  involvement  of  the  bladder  whatever,  the  inflammation 
being  quite  sharply  limited  to  the  membranous  and  prostatic  urethra. 

The  inflammatory  process,  however,  may  invade  the  bladder  in  part 
or  in  totality.  In  the  majority  of  cases  only  that  portion  of  the  bladder 
near  the  internal  urethral  orifice,  particularly  on  its  sides  and  also  at  the 
base  or  trigone,  is  attacked.  This  limited  bladder-inflammation,  together 
with  posterior  urethritis,  constitutes  what  is  known  as  "  urethrocystitis." 

This  morbid  process,  however,  may  extend,  and  in  time  involve  the 
whole  bladder,  in  which  event  there  is  a  true  cystitis  resulting  from 
gonorrhceal  inflammation. 

Acute  Urethro- cystitis. 

Urethro-cystitis  may  be  acute,  subacute,  or  chronic.  When  the 
inflammation  is  still  acute,  and  that  portion  of  the  bladder  near  its  neck 
becomes  swollen  and  red  and  secretes  pus,  the  symptoms  are  those  of 
acute  posterior  urethritis  intensified.  These  are  mostly  tenesmus,  pain 
at  the  end  of  micturition,  and  perhaps  hsematuria.  Examination  of  the 
urine  shows  opacity  in  the  two  cylinders,  but  instead  of  the  second  speci- 
men being  less  cloudy  than  the  first,  as  is  the  case  in  posterior  urethritis, 
it  is  as  cloudy,  and  even  may  be  more  cloudy,  than  the  first.  In  some 
cases,  but  not  in  all,  if  the  patient  urinates  into  three  glasses,  the  urine 
in  the  first,  which  clears  out  the  posterior  urethra,  will  be  very  cloudy, 
the  second  specimen  less  so,  while  the  contents  of  the  third  glass,  which 
come  directly  from  the  inflamed  viscus  in  a  state  of  tonic  contraction, 
will  be  very  cloudy,  owing  to  the  forcible  extrusion  of  pus  from  the 
texture  of  the  mucous  membrane.  If  hemorrhage  is  small,  only  the 
third  portion  will  contain  blood,  but  if  it  is  copious,  all  three  specimens 
will  contain  it. 

The  urine  is  usually  of  acid  reaction,  and  presents  a  greenish  opaque 
appearance.  Whenever  the  tenesmus  is  great,  albumin  may  be  present. 
Alkalinity  of  the  urine  may  be  caused  by  pronounced  haematuria. 
When  allowed  to  stand,  as  a  rule  the  tissue-products  do  not  settle 
promptly ;  hence  fully  twenty -four  hours  may  elapse  before  the  pus, 
epithelium,  and  mucus  have  settled  to  the  bottom  of  the  cylinder.  Then 
we  see  a  grayish  granular  and  quite  thick  layer,  in  which  are  pus-cells 
and  bladder-epithelium  ;  if  hematuria  exists,  there  is  a  red  layer  of 
blood  over  this,  and  floating,  cloud-like,  over  all  is  the  readily  movable 
layer  of  mucus. 


104  COMPLICATIONS  OF  GONORRHCEA. 

Subacute  and  Chronic  Urethro- cystitis. 

Besides  the  prompt  and  acute  invasion  of  the  lower  part  of  the  blad- 
der from  the  posterior  urethra  which  has  just  been  considered,  there  is 
a  subacute  and  chronic  form  which  is  equally  as  common. 

Subacute  urethro-cystitis  may  develop  as  a  result  of  an  exacerbation 
of  chronic  posterior  urethritis.  When  this  occurs,  it  is  usually  as  a 
result  of  sexual  and  alcoholic  excesses,  great  physical  strain,  particularly 
in  horseback  riding,  wrestling,  and  bicycling.  Exposure  to  cold  in  the 
various  ways  incident  to  daily  life  is  also  productive  of  this  extension. 
In  some  cases  long  delay  in  urination,  and  in  others  the  introduction  of 
catheters  or  sounds,  have  caused  the  phlegmasia  to  spread  from  its 
urethral  seat  to  the  bladder-walls. 

In  cases  of  subacute  and  chronic  urethro-cystitis  the  symptoms  are 
similar,  but  less  pronounced  than  in  the  acute  form.  As  the  chronicity 
of  the  case  increases,  the  tenesmus  and  other  symptoms  may  grow  much 
less  and  in  some  chronic  cases  cease  to  exist.  In  some  cases  of  first 
attack,  as  well  as  in  relapses  later  in  the  declining  stage,  patients  com- 
plain of  a  dull  and  uneasy  sensation  long  after  urination,  and  they  speak 
of  a  feeling  as  if  the  bladder  yet  contained  urine.  The  catheter  being 
passed,  half  an  ounce  to  an  ounce,  or  even  more,  of  urine  flows  out.  In 
these  cases,  owing  to  the  swelling  in  the  mucous  membrane  and  its  sub- 
jacent connective  tissue,  the  bladder  is  unable  to  expel  all  of  its  con- 
tents. This  uneasy  sensation  is  in  marked  contrast  with  the  sharp, 
sometimes  radiating,  pains  felt  at  the  end  of  urination.  As  a  result  of 
the  chronic  inflammation,  in  some  rare  cases  a  villous  condition  of  the 
mucous  membrane  around  and  near  the  bladder-neck,  as  shown  by  a 
quite  thickened  and  velvety  appearance,  is  produced,  which  gives  rise 
to  hematuria,  particularly  at  the  end  of  urination.  In  some  of  these 
cases  the  existence  of  a  bladder-tumor  might  very  properly  be  sus- 
pected. 

Microscopical  examination  of  the  urine  of  urethro-cystitis  shows  a 
conglomeration  of  tissue-products.  The  various  forms  of  epithelial  cells 
derived  from  the  posterior  urethra  will  be  found  inextricably  mixed  with 
the  large  flat  bladder-epithelium.  These,  with  pus-cells,  mucous  cor- 
puscles (perhaps  a  few  gonococci),  many  and  varied  cocci  and  bacteria, 
and  blood-corpuscles,  cover  the  whole  field. 

Treatment. — In  acute  urethro-cystitis  the  patient  should  at  once 
assume  the  recumbent  position.  A  plain,  bland  diet  of  bread  and  milk, 
and  rice  and  Indian  meal  with  milk,  should  be  ordered.  The  bowels 
should  at  once  be  acted  upon  and  kept  mildly  relaxed.  Pain  may  be 
relieved  by  suppositories,  or  by  opium  by  the  mouth  or  morphine  by 
hypodermic  injection.  If  there  is  much  suprapubic  pain,  an  ice-bag 
may  be  carefully  applied  and  kept  on  if  it  affords  comfort.     In  some 


CYSTITIS.  105 

cases  a  hot-water  bag  or  hot  flaxseed  poultice  will  be  indicated.     Hot 
sitz-baths  and  full  hot  baths  may  be  beneficial. 

In  the  very  acute  stage  all  treatment  by  injections  should  be  stopped. 

Infusions  of  buchu  and  of  uva-ursi  sometimes  seem  beneficial. 
The  fluid  extracts  of  triticum  repens  and  of  kava-kava  also  may  be 
used,  either  alone  or  in  combination.  Thirty  drops  of  each  in  plenty 
of  water,  with  two  or  three  drops  of  laudanum  when  the  pain  is  severe, 
may  be  given  every  three  or  four  hours.  When  opium  in  any  form 
is  administered,  the  condition  of  the  bowels  must  be  carefully  looked 
after  and  constipation  avoided,  either  by  the  use  of  enemata  or  of 
aperients  or  cathartics. 

In  some  cases  alkalies  produce  a  soothing  effect.  Bicarbonate  of 
potassa  and  citrate  of  potassa  in  thirty-grain  doses,  dissolved  in  water 
or  carbonic  water,  may  be  given  three  times  a  day.  With  the  decline 
of  the  acute  and  the  onset  of  the  subacute  or  chronic  stage  the  use  of 
antiblennorrhagics — cubebs,  copaiba,  and  oil  of  santal — may  be  of  signal 
service  in  some  cases,  whereas  in  others  they  may  cause  actual  discom- 
fort. Their  effect,  then,  should  be  carefully  watched,  and  if  they  give 
decided  relief,  they  may  be  continued ;  if  not,  discarded.  Irrigations 
into  the  bladder  of  warm  boric  or  salt  solutions  combined  with  lauda- 
num may  give  comfort  to  the  patient. 

In  the  subacute  and  chronic  stages  the  most  reliance  is  to  be  placed 
on  the  action  of  solutions  of  nitrate  of  silver,  used  at  first  very  weak 
and  increased  as  the  treatment  is  continued.  In  many  cases  much 
benefit  follows  the  injection  into  the  posterior  urethra  of  a  hand-syringe- 
ful  of  a  warm  solution  of  nitrate  of  silver  (1  :  16,000,  and  as  strong  as 
1 :  4000).  This  agent  irrigates  the  posterior  urethra  and  passes  into 
the  bladder,  upon  the  lower  part  of  which  it  acts  beneficially.  It  may 
be  retained  for  a  few  minutes,  and  then  voided,  and  as  it  passes  out 
it  again  affects  the  morbid  surfaces.  Such  an  irrigation  may  be  made 
daily,  but  the  sensations  of  the  patient  must  be  the  guide  in  deciding 
its  frequency.  As  the  case  progresses  the  strength  of  the  solution 
should  be  cautiously  increased,  until  toward  the  last  instillations  of 
stronger  solutions  of  nitrate  of  silver  (see  Treatment  of  Posterior 
Urethritis)  are  resorted  to. 

Solutions  of  permanganate  of  potassium,  1  :  3000  or  1  :  6000,  also 
produce  good  results  in  some  cases. 

CYSTITIS. 

This  affection  may  be  acute  or  chronic. 

Acute  gonorrhceal  cystitis — meaning  inflammation  of  the  whole  of 
the  mucous  membrane  of  the  bladder — is  a  very  rare  complication  of 
gonorrhoea,  since  acute  posterior  urethritis,  even  when  it  invades  the 


106  COMPLICATIONS  OF  GONORRHOEA. 

bladder,  usually  only  involves  an  inch  or  two,  or  perhaps  more,  of 
tissue  near  the  internal  sphincter.  Very  exceptionally  the  inflamma- 
tion extends  and  involves  the  totality  of  the  mucous  membrane.  In 
these  cases  the  symptoms  are  still  those  of  acute  posterior  urethritis, 
besides  which  there  may  be  pain  over  the  symphysis  pubis,  malaise,  and 
fever.  The  urine  is  very  opaque  and  contains  bladder-epithelium,  pus, 
and  bacteria. 

When  the  urine  is  tested  in  these  cases  the  second  and  third  speci- 
mens are  even  cloudier  than  the  first.  In  the  earlier  stages  the  urine  is 
acid  and  has  no  foul  smell ;  later  it  may  be  alkaline  and  offensive. 

This  form  of  cystitis  may  end  in  one  or  two  months,  but  there  is  a 
marked  tendency  in  these  cases  for  the  process  to  become  subacute  and 
chronic. 

Chronic  gonorrheal  cystitis  is  a  very  persistent  affection,  and  often 
resists  the  most  intelligent  treatment  directed  against  it.  Usually, 
with  the  involvement  of  the  whole  bladder  the  symptoms  of  posterior 
urethritis  cease,  except  perhaps  that  a  slightly  increased  frequency  of  uri- 
nation remains.  In  the  older  cases  we  frequently  hear  patients  com- 
plain of  a  burning  or  scalding  pain  on  urination,  with  uneasiness 
sometimes  amounting  to  a  paroxysm  of  pain  at  the  end  of  the  act. 
Urination  may  be  very  frequent  both  during  the  day  and  the  night. 
With  the  continuance  of  the  cystitis  the  morbid  process,  which  at 
first  was  superficial,  involves  the  deeper  part  of  the  mucous  mem- 
brane, and  forms  what  is  called  "  parenchymatous  cystitis."  Progress- 
ing farther,  ulceration  of  the  bladder  may  result  or  the  morbid  process 
may  extend  up  the  ureters,  involving  them  and  then  attacking  the  kid- 
neys and  the  pelves.  In  cases  of  chronic  parenchymatous  cystitis  the 
urine  is  usually  alkaline,  and  has  a  very  foul,  even  feculent,  odor. 

Diagnosis. — The  diagnosis  of  gonorrhceal  cystitis  is  to  be  made  by 
a  study  of  the  history  of  the  case  and  of  its  symptoms,  together  with 
examination  of  the  urine.  The  urine  varies  according  to  the  severity 
and  chronicity  of  the  cystitis.  It  may  be  simply  purulent  urine  of  acid 
reaction,  or  alkaline  and  fetid.  The  three-glass  test  will  show  cloudiness 
in  each  specimen,  more  particularly  in  the  last.  In  this  connection  it  is 
important  to  remember  that  urine  alkaline  from  phosphates,  carbonates, 
and  urates  very  commonly  has  the  cloudy  look  of  purulent  urine,  but 
its  nature  is  soon  revealed  by  a  simple  method.  If  the  cloudiness  is 
due  to  urates  or  uric  acid,  it  vanishes  by  the  use  of  heat.  If  it  is  due 
to  phosphates,  carbonates,  or  pus,  heat  increases  the  turbidity,  but  a 
few  drops  of  acetic  acid  will  clear  up  phosphaturia  and  carbonuria 
(the  latter  with  much  effervescence),  while,  if  the  opacity  then  remains, 
it  is  caused  by  pus  or  bacteria. 

In  all  cases  the  microscope  should  be  constantly  used  in  the  exami- 


CYSTITIS.  107 

nation  of  the  urine,  and  the  following  features  will  generally  be  found 
reliable  guides  in  diagnosis  :  If  the  cystitis  is  still  rather  young  and  the 
urine  is  still  acid,  on  its  examination  various  forms  of  urethral  epithe- 
lium, bladder-epithelium,  and  pus  will  be  discovered.  This  combination, 
the  history  being  in  accord,  will  usually  warrant  a  diagnosis  of  cystitis. 
When  the  process  is  old  and  the  urine  alkaline,  withered-up  pus-cells, 
bladder-epithelium,  and  triple  phosphate  will  dominate  the  field  and 
establish  the  diagnosis.  The  absence  of  casts  and  renal  epithelium  will 
show  that  the  morbid  process  is  still  confined  to  the  bladder. 

Chronic  cystitis  from  gonorrhoea  is  usually  found  in  young  and 
middle-aged  patients ;  cystitis  from  stricture  and  hypertrophy  of  the 
prostate  is  usually  found  in  more  advanced  subjects. 

Pathology. — The  pathology  of  gonorrhceal  cystitis  is  not  yet  clearly 
demonstrated.  In  acute  cases  of  posterior  urethritis  the  pus  quite 
commonly  contains  the  gonococcus ;  but  as  the  process  grows  old  this 
microbe  disappears  and  other  forms  of  cocci  seem  to  take  its  place. 
This  same  condition  is  observed  in  the  pus  of  urethro-cystitis  and 
of  cystitis,  in  the  secretions  of  which  it  is  impossible  to  find  the  gono- 
coccus, except  rarely  in  very  small  numbers,  but  myriads  of  cocci  and 
bacteria  may  be  plainly  seen.  Much  study  is  necessary  to  clear  up  this 
interesting  subject.  The  theory  of  a  mixed  infection  being  the  cause  of 
this  trouble  suggests  itself,  but  it  cannot,  as  yet,  be  strongly  urged. 

Treatment. — The  diagnosis  being  made,  and  the  absence  of  strict- 
ure being  determined,  general  and  local  treatment  should  be  instituted. 
The  diet  must  be  regulated  and  be  confined  to  bland,  easily-digestible 
articles.  Coffee,  spices,  beer,  alcoholics,  are  to  be  interdicted.  As 
much  bodily  quiet  and  ease  as  possible  should  be  observed.  In  these 
cases  care  must  be  exercised  in  the  use  of  alkalies,  which  some  physi- 
cians seem  by  instinct  to  prescribe  indiscriminately.  The  tendency  is 
toward  alkalinity  of  the  urine ;  therefore  we  should  be  on  our  guard. 

When  the  urine  is  alkaline,  urotropin,  dilute  nitric  acid,  dilute  nitro- 
muriatic  acid,  and  dilute  muriatic  acid  may  produce  decided  benefit. 
Salol,  salicylate  of  sodium,  benzoic  acid,  and  salicine  may  be  of  benefit 
in  tending  to  restore  an  aseptic  condition  of  the  bladder,. which  is  the 
chief  aim  of  treatment. 

Warm  irrigations  of  saturated  boric  solution,  to  which  a  little 
laudanum  may  be  added,  may  be  of  benefit  for  a  time.  Then  the 
indications  are  for  the  use  of  more  decidedly  active  irrigations,  such  as 
nitrate  of  silver,  permanganate  of  potassium,  and  in  some  cases  of 
alum  and  sulphate  of  zinc  in  combination.  The  strength  of  these 
solutions  should  be  adapted  to  the  case,  and  their  action  should  be  care- 
fully watched.  In  some  cases  benefit  follows  irrigation  with  solutions 
of  bichloride  of  mercury.     It  is  well  to  begin  with  the  strength  of 


108  COMPLICATIONS  OF  GONORRHOEA. 

1  :  30,000,  and  increase  if  progress  is  made,  or  desist  if  a  feeling  of  dis- 
comfort is  produced. 

These  cases  are  frequently  very  trying  to  the  patient  and  to  the 
surgeon,  whose  therapeutic  armamentarium  they  often  sorely  tax. 

As  a  last  resort,  perineal  section  should  be  performed  and  the  blad- 
der irrigated  and  drained. 

INFLAMMATION  OF   THE   SEMINAL  VESICLES. 

Seminal  vesiculitis,  or  spermato-cystitis,  may  be  acute  or  chronic,  aud 
is  almost  always  secondary  to  gonorrhoea  or  to  hyperemia  of  the  poste- 
rior urethra  due  to  masturbation  and  venereal  excesses,  or  to  inflamma- 
tion of  this  region  resulting  from  traumatism,  catheterization,  endoscopy, 
and  strong  injections. 

The  symptoms  of  the  acute  form  of  seminal  vesiculitis  are  quite 
similar  to  those  of  posterior  urethritis  and  to  those  given  as  diagnostic 
of  the  several  varieties  of  prostatitis.  The  patient  first  experiences 
pain,  either  of  a  dull  or  throbbing  character,  or  a  sensation  of  weight, 
which  he  refers  to  the  deep  portion  of  the  pelvis  just  within  the  anus  or 
at  the  neck  of  the  bladder  or  in  the  perineum.  There  is  a  markedly 
increased  frequency  in  urination,  and  tenesmus  sometimes  mild,  again 
quite  decided,  and  in  some  cases  very  severe.  As  the  bladder  fills  the 
painful  symptoms  increase  in  severity,  and  there  may  be  pain  at  the  end 
and  sometimes  at  the  root  of  the  penis.  There  may  be  fever,  chills, 
and  malaise.  All  these  symptoms  may  be  present  in  posterior  ure- 
thritis, so  that  the  crucial  test  in  diagnosis  is  palpation  of  the  prostate 
and  seminal  vesicles  by  means  of  the  finger  in  the  rectum.  If  seminal 
vesiculitis  is  present  and  explored  for  early,  one  or  both  vesicles  will  be 
found  to  be  much  enlarged  in  all  directions  in  the  shape  of  a  distended 
leech,  hot,  brawny,  and  exquisitely  tender.  In  a  few  days  the  swelling 
may  still  further  increase,  and  then  moderate  fluctuation  may  be  felt. 
In  some  of  these  cases  the  patient  presents  a  pitiable  spectacle.  He 
suffers  from  pain  in  the  perineum,  rectum,  bladder,  and  at  the  top  of 
the  sacrum.  He  has  frequent  desire  to  urinate,  and  the  act  is  attended 
with  much  pain,  or,  again,  in  some  cases,  there  is  very  distressing 
dysuria.  Defecation  is  very  painful,  and  perhaps  complicated  with 
rectal  tenesmus,  and  may  be  attended  with  vesical  spasms ;  sleep  is 
heavy  and  unrefreshing,  and  often  during  the  night  painful  erections 
and  pollutions,  perhaps  bloody,  may  add  to  the  patient's  sufferings. 
The  urine  may  contain  pus  and  epithelial  cells,  but  these  tissue-elements 
may  be  absent  for  hours  or  for  days,  during  which  the  urine  is  clear  ; 
and  in  this  feature  acute  seminal  vesiculitis  differs  from  acute  posterior 
urethritis,  in  which  the  discharge  of  pus  or  blood  is  constantly  seen. 
At  the  onset,  and  early  in  the  course,  of  seminal  vesiculitis  the  gonor- 


INFLAMMATION  OF  THE  SEMINAL    VESICLES.  109 

rhoeal  discharge  may  disappear  entirely,  and  in  this  it  resembles  epi- 
didymitis. But  in  a  short  time  the  discharge  reappears,  and  it  may  be 
more  or  less  bloody.  In  seminal  vesiculitis  the  blood  is  mixed  with 
pus  or  the  latter  is  streaked  with  it ;  whereas  in  posterior  urethritis 
the  blood  follows  the  act  of  urination  or  there  may  be  a  worm-like 
thread  of  coagulated  blood  with  the  first  jet  of  the  urine. 

The  inflammatory  stage  of  seminal  vesiculitis  is  usually  quite  acute, 
and  at  the  end  of  a  week  or  ten  days  the  symptoms  become  ameliorated 
and  resolution  gradually  sets  in.  In  all  probability,  in  many  cases  the 
parts  sooner  or  later  become  normal.  In  some  cases  after  resolu- 
tion of  the  vesicular  inflammation  the  urethral  discharge  reappears, 
while  in  others  the  urethra  is  left  in  a  healthy  condition.  In  this  acute 
stage  of  inflammation  the  morbid  process  resembles  that  of  gonorrhoea 
in  the  redness  and  swelling  of  the  mucous  membrane  and  in  the  sub- 
mucous cell-increase.  When,  however,  the  inflammation  becomes 
intense,  a  true  suppurative  process  or  abscess  forms,  in  which  event  the 
local  and  general  symptoms  are  more  pronounced  and  the  sufferings  of 
the  patient  greater.  Kectal  exploration  then  reveals  a  large  boggy, 
painful  swelling  at  the  base  of  the  bladder,  beyond  and  to  the  outer 
edge  of  the  prostate. 

While  the  ejaculatory  duct  of  the  seminal  vesicle  remains  patulous 
the  contained  pus  may  escape,  or  perhaps  may  be  massaged  by  means 
of  the  finger-tip,  into  the  urethra,  in  which  event  complete  resolution 
without  ulterior  bad  results  may  occur.  If,  however,  the  duct  becomes 
occluded  by  the  swelling  of  its  mucous  membrane  or  by  being  plugged 
up  by  sympexia  or  masses  of  mucus  dislodged  from  the  diverticula  of 
the  vesicle,  the  abscess  may  attain  a  very  large  size,  and  the  pus  may 
perforate  its  wall  and  burst  into  the  ischio-rectal  fossa  or  around  the 
rectum  into  the  bladder,  the  rectum,  and  the  peritoneum,  sometimes 
causing  death  from  septicaemia,  and  generally  leading  to  the  formation 
of  fistulous  tracts.  The  intimate  relations  of  the  vas  deferens,  the 
ejaculatory  duct,  and  the  seminal  vesicles  are  such  that  the  last  struct- 
ures and  the  testicles  may  be  involved  at  the  same  time.  It  is  probable 
that  in  many  cases  seminal  vesiculitis  and  epididymitis  coexist,  but  that 
the  violence  of  the  symptoms  of  the  testicular  trouble  masks  that  of  the 
vesicular  affection.  It  is  also  very  probable  that  the  intrapelvic  pain 
which  so  frequently  accompanies  acute  epididymitis,  and  which  we 
have  been  taught  is  due  to  a  complicating  phlegmasia  of  the  pelvic  part 
of  the  vas  deferens,  is  sometimes  really  symptomatic  of  involvement  of 
the  seminal  vesicle.  There  is  a  field  for  observation  in  this  direction, 
and  much  may  be  learned  from  digital  exploration  of  the  rectum  in 
cases  of  acute  testicular  inflammation. 

It  can  be  readily  understood,  after  a  consideration  of  the  foregoing 


110  COMPLICATIONS  OF  GONORRHOEA. 

facts,  why  acute  seminal  vesiculitis  has  been  wrongly  diagnosticated  as 
posterior  urethritis,  as  acute  prostatitis,  and  as  inflammation  of  the 
vesical  neck  and  floor  of  the  bladder. 

Chronic  Seminal  Vesiculitis. 

This  form  of  seminal  vesiculitis  may  result  from  the  non-occurrence 
of  resolution  in  the  acute  affection,  and  in  this  event  the  clinical  history 
is  tolerably  clear  and  striking  ;  but  in  the  majority  of  cases  of  chronic 
seminal  vesiculitis  it  begins  as  a  low-grade  inflammatory  process  in 
persons,  particularly  of  neurotic  or  neurasthenic  types,  who  may  suffer 
from  chronic  subacute  posterior  urethritis  or  chronic  prostatitis,  and  in 
confirmed  masturbators  and  in  those  given  to  excessive  venery  and 
alcoholics.  The  difficulty  in  the  study  of  the  chronic  form  of  seminal 
vesiculitis  is  that  in  many  cases  the  symptoms  are  so  few  and  so  vague, 
and  point  so  indefinitely,  if  at  all,  to  trouble  in  these  vesicles,  that 
oftentimes  their  origin  is  not  suspected  by  the  physician.  Then,  again, 
cases  are  seen  in  which  the  svmptoms  are  verv  clearly  and  strongly 
marked,  yet  they  may  be  with  seemingly  good  reason  attributed  to 
trouble  in  the  posterior  urethra  and  in  the  prostate. 

Cases  of  chronic  seminal  vesiculitis  which  follow  quite  directly  a 
recent  or  more  or  less  remote  attack  of  gonorrhoea,  very  often  present 
such  a  group  of  symjrtoms  that  the  surgeon  is  led  to  suspect  their  origin 
in  inflammation  of  the  seminal  vesicles,  particularly  if  no  trouble  is 
found  in  the  posterior  urethra.  Such  patients  state  that  since  an  attack 
of  gonorrhoea  or  a  relapse  they  have  not  felt  well  as  regards  their  sexual 
organs.  Some  complain  that  they  are  sexually  weak,  that  they  have 
little  desire,  or  that  they  have  premature  and  perhaps  painful  ejacula- 
tions, which  in  some  cases  are  mixed  with  blood.  Others,  again,  are 
subject  to  a  constant  slight  or  profuse  discharge  which  is  of  a  mucous 
or  muco-purulent  character.  Again,  this  form  of  discharge  may  be 
intermittent.  There  may  be,  however,  a  decided  chronic  seminal  vesic- 
ulitis without  any  perceptible  discharge.  Xot  infrequently  patients 
having  a  history  of  one  or  more  attacks  of  gonorrhoea  state  that 
they  suffer  from  a  mild  or  moderately  severe,  even  burning,  pain  or 
itching,  or  a  sense  of  weight  in  the  course  of  the  urethra,  in  the  peri- 
neum, bladder,  anus,  and  rectum.  In  addition  to  this  they  often  give  a 
history  of  sexual  erethism  with  or  without  gratification  in  coitus,  and 
sometimes  of  increased  desire,  while  little  relief,  or  even  aggravation 
of  symptoms,  may  follow  the  sexual  act. 

In  pronounced  masturbators  and  in  those  given  to  excessive  sexual 
indulgence,  particularly  with  the  addition  of  alcoholic  excesses,  chronic 
seminal  vesiculitis  may  sometimes  be  found.  These  cases  are  often 
amemic,  neurotic,  and  neurasthenic  subjects  who  respond  very  indiffer- 


CHRONIC  SEMINAL    VESICULITIS.  Ill 

ently  to  treatment.  Such  patients  may  complain  of  some  pain  or  dis- 
turbance in  the  urethra,  bladder,  anus,  or  rectum,  and  they  may  present 
a  discharge ;  then,  again,  all  these  symptoms  may  be  wanting.  Most 
of  them,  however,  give  a  history  of  disturbances  in  the  sexual  function. 
The  disturbances  are  mainly  of  two  forms  ;  first  those  of  lowered  power, 
and,  second,  those  of  erethism  of  the  sexual  organs.  In  the  first  order 
of  cases  we  find  absence  or  incompleteness  of  erections  and  pollutions 
from  slight  causes,  without  enlargement  of  the  penis.  In  these  cases 
there  is  often  a  haunting  desire  for  erection,  with  no  response.  Very 
often  these  patients  suffer  from  a  constant  dribbling  of  a  dirty  gray  or 
brownish  mucus,  which  may  during  the  day  be  so  copious  as  to  saturate 
one  or  two  pocket  handkerchiefs.  Then,  again,  some  of  these  patients 
have  no  such  discharge,  but  an  emission  of  a  thin,  gray,  watery,  and 
sometimes  brownish  and  even  curdy  fluid  occurs  daily  or  more  fre- 
quently. Such  is  the  erotic  condition  of  these  patients  that  the  sight  of 
a  pretty  woman,  of  her  breast  or  her  ankle,  throws  them  into  a  high 
state  of  nervousness  and  sexual  erethism.  Accidental  slight  contact, 
the  glance  of  the  eye,  the  sound  of  the  voice,  and  the  grasp  of  the  hand 
serve  so  to  excite  these  men  sexually  that  an  orgasm,  with  partial  erec- 
tion, results. 

These  cases  run  a  somewhat  peculiar  course.  In  some  the  symptoms 
and  conditions  continue  in  a  more  or  less  subdued  manner,  and,  though 
they  disturb  the  patients  considerably,  the  latter  arrive  at  a  state  of 
mind  by  which  they  bear  their  troubles  more  or  less  philosophically. 
In  this  class  of  cases  the  affection  runs  on  from  year  to  year  in  a 
monotonous  way.  Such  patients  are  neither  healthy  nor  very  sick. 
But  cases  are  sometimes  seen  in  which  the  chronic,  uneventful  course 
of  the  affection  is  varied  by  the  development  of  more  or  less  severe 
exacerbations.  In  this  event  the  health  becomes  deteriorated,  the 
patients  lose  their  appetite  and  weight,  and  present  the  appearance  of 
very  weak  and  sick  men.  Concomitantly  with  this  condition  the  nerv- 
ous system  becomes  much  disturbed  and  the  patients  present  the  symp- 
toms of  neurasthenia.  A  nervous  apprehension  and  anxiety  are  very 
frequent  concomitants.  Such  an  exacerbation  may  last  one  month  or 
many  months,  and  may  lead  to  permanent  invalidism. 

Diagnosis. — The  diagnosis  of  seminal  vesiculitis,  in  whatever  form 
it  may  exist,  is  to  be  arrived  at  mainly  through  palpation  of  the  parts 
by  the  finger  inserted  into  the  rectum.  It  has  already  been  shown  how 
little  light  the  subjective  symptoms  throw  upon  the  nature  of  the 
trouble.  It  is  always  well  that  the  bladder  should  be  slightly  dis- 
tended, for  in  that  condition  the  vesicles  are  more  readily  detected. 
Then  the  finger  (which  should  be  a  long  one)  is  introduced  into  the 
rectum,  and,  haviug  defined  the  outline  of  the  prostate,  the  vesicles  are 


112  COMPLICATIONS  OF  GOXORRHCEA. 

sought  for  above  and  to  the  outside  of  this  body.  The  examination 
may  be  made  with  the  patient  lying  on  his  back  or  standing  up  with 
the  body  bent  at  right  angles  to  the  legs,  which  are  slightly  separated. 
Abdominal  pressure,  exerted  deep  down  and  toward  the  pelvis,  may 
often  afford  much  aid  in  these  examinations. 

At  the  prostate  the  two  vesicles  approach  to  within  a  finger's  breadth 
of  one  another,  and  on  the  inner  side  of  each  is  the  vas  deferens,  which 
at  this  part  frequently  becomes  much  ampullated.  The  seminal  vesi- 
cles in  health  have  a  firm,  somewhat  resistant  structure,  which,  while 
not  presenting  a  brawny  feel  to  the  touch,  gives  the  sensation  of  having 
tolerably  thick  walls.  Therefore  the  surgeon  must  not  enter  upon  the 
examination  with  the  idea  that  he  is  to  feel  two  oblong,  rather  soft,  and 
readily-compressible  little  bladders. 

If  diseased,  the  seminal  vesicles  will,  in  the  acute  stage,  feel  much 
swollen  in  all  directions,  tender,  perhaps  hot,  and  may  present  a  doughy 
sensation,  like  that  of  the  over-filled  leech.  In  the  stage  of  abscess  the 
swelling  will  be  great,  the  pain  intense,  and  the  symptoms  severe  and 
pointing  to  intrapelvic  trouble. 

In  the  chronic  forms  a  large  flabby  tumor  may  be  felt.  If  both 
vesicles  are  involved,  the  base  of  the  bladder  beyond  the  prostate  is  the 
seat  of  the  tumor,  which  is  usually  of  goodly  size,  often  very  large.  In 
chionic  cases  the  surgeon  must  always  remember  that  the  posterior 
urethra  may  be  the  seat  of  a  low  grade  of  inflammation,  and  that  the 
prostate  may  also  be  at  least  hypereemic.  This  same  caution  applies 
very  strongly  to  the  cases  of  old  men  who  are  suffering  from  enlarge- 
ment of  the  prostate  and  also  from  a  chronic  inflammatory  condition 
of  the  seminal  vesicles — a  complication  which  is  sometimes  met 
with. 

Examination  and  manipulation  of  the  seminal  vesicles  by  means  of 
the  finger-tip  may  cause  a  flow  of  pus,  with  perhaps  blood,  into  the 
urethra  when  the  inflammation  is  recent  and  active.  In  the  subacute 
cases  the  discharge  is  muco-purulent  and  mucoid,  containing  masses  of 
inspissated  semen,  and  of  mucus,  sympexia,  and  sometimes  very  minute 
calcareous  concretions. 

Pathology. — In  the  acute  gonorrheal  stage  it  is  probable  that  the 
lesion  of  the  mucous  membrane  is  similar  to  that  of  gonorrhoea  of  the 
urethra.  In  the  main,  the  morbid  process  consists  of  swelling  of  the 
mucous  membrane  and  small  round-cell  thickening  in  the  submucous 
connective  tissue.  The  vesicles  then  may  be  much  dilated,  or,  again, 
they  may,  by  contraction  of  the  newly-formed  tissue,  become  much 
shrivelled. 

Prognosis. — In  the  acute  form  of  this  trouble  resolution  usually 
takes    place.     In    the    chronic    forms    amelioration    and    cure    may  be 


EPIDIDYMITIS  AND  EPIDIDYMO-ORCHITIS.  113 

obtained.  In  some  cases,  however,  the  morbid  process  goes  on  to  the 
formation  of  large  tumors  which  require  operative  measures. 

Treatment. — When  recognized  in  the  acute  stage,  seminal  vesicu- 
litis is  to  be  treated  on  the  general  principles  which  govern  the  manage- 
ment of  acute  inflammation  of  the  genito-urinary  organs.  Rest  in  bed, 
alkaline  mixtures,  and  gentle  purgation  are  necessary.  Leeches  may  be 
used  quite  freely  around  the  margin  of  the  anus  and  over  the  perineum. 
Rectal  irrigations  of  cold  or  hot  water  by  means  of  Kemp's  double-cur- 
rent hard-rubber  irrigator  may  be  administered  several  times  a  day  if 
they  are  grateful  to  the  patient  and  allay  inflammation.  Opium  and 
belladonna  suppositories  may  be  employed  if  necessary  to  relieve  pain 
and  tenesmus. 

Should  an  abscess  form,  the  patient  is  placed  in  the  lithotomy  posi- 
tion and  the  pus  evacuated  by  means  of  a  long  incision,  in  the  perineum 
just  anterior  (about  three-quarters  of  an  inch)  to  the  anus,  great  care 
being  taken  that  the  membranous  urethra,  the  prostate,  and  the  rectum 
are  not  cut.  In  this  operation  much  aid  will  be  given  by  means  of  the 
finger  in  the  rectum  and  a  sound  in  the  urethra.  The  incision  may  be 
made  in  the  median  line  laterally,  or,  if  both  vesicles  are  the  seat  of 
acute  suppuration,  it  may  be  crescentic.  Then  the  dissection  between 
the  base  of  the  bladder  and  the  rectum  must  be  cautiously  made. 

In  the  treatment  of  chronic  seminal  vesiculitis,  in  which  we  may 
find  distended  pouchy  vesicles,  benefit  may  result  from  massaging  the 
vesicles.  This  procedure  is  accomplished  by  the  finger-tip  gently  but 
firmly  pressing  or  kneading  as  much  of  the  organ  as  is  within  reach 
from  above  downward,  so  as  to  express  the  contents  through  the  ejacu- 
latory  duct  into  the  prostatic  urethra. 

Cases  of  chronic  seminal  vesiculitis  in  which  there  is  neurasthenia, 
debility  and  often  great  mental  depression  belong  largely  to  the 
domain  of  general  medicine.  Such  cases  require  good  hygiene — if 
possible  an  entire  change  of  scene,  rest,  and  pleasant  surroundings. 
Tonics  combined  with  nux  vomica  and  ergot  produce  much  benefit. 
Iron,  quinine,  and  coca  are  also  indispensable  in  some  cases.  The 
urethra,  bladder,  prostate,  and  seminal  vesicles  should  be  very  care- 
fully examined  by  instruments  and  by  inspection  of  the  urine.  If 
there  is,  as  so  frequently  happens,  a  coexistent  posterior  urethritis,  this 
should  be  properly  treated. 

EPIDIDYMITIS   AND   EPIDIDYMO-ORCHITIS. 

The  most  frequent  complication  of  gonorrhoea  is  an  inflammation  of 
the  epididymis  which  may  be  sharply  limited  to  that  appendage  or  it 
may  also  involve  the  testicle.  The  former  is  called  "epididymitis," 
and  the  latter  "  epididymo-orchitis,"   and  both  are   known   under  the 


114  COMPLICATIONS  OF  GONORRHOEA. 

title  "  swelled  testicle."  In  some  cases  of  swelled  testicle  there  is  a 
concomitant  inflammation  of  the  vas  deferens  in  more  or  less  of  its 
extent,  and  to  this  phlegmasion  the  terms  "  deferentitis  "  and  "  funicn- 
litis  "  have  been  applied.  This  complication  is  also  called,  less  correctly, 
"  inflammation  of  the  spermatic  cord "  when  that  portion  near  or  in 
immediate  continuity  with  the  epididymis  is  involved.  Acute  inflam- 
mation of  the  tunica  vaginalis,  or  vaginalitis,  with  a  greater  or  less 
amount  of  effusion,  also  occurs  in  cases  of  swelled  testicle,  particularly 
when  the  morbid  process  is  centred  in  the  epididymis. 

There  is  very  frequently  in  cases  of  epididymis  and  epididymo- 
orchitis  a  swollen  and  painful  condition  of  the  vas  deferens  as  it  leaves 
the  epididymis  and  ascends.  This  swelling  of  the  vas  may  extend  an 
inch  and  even  more  up  the  tube.  It  is  usually  lost  sight  of  by  reason 
of  the  greater  prominence  and  painfulness  of  the  testicular  phlegmasia. 

Swelled  testicle,  therefore,  may  consist  only  of  inflammation  of  the 
epididymis  ;  but  this  is  usually  complicated  with  acute  inflammation  and 
more  or  less  copious  effusion  into  the  cavity  of  the  tunica  vaginalis. 
This  combination,  with  in  some  cases  some  involvement  of  the  vas 
deferens,  constitutes  the  majority  of  the  cases  of  swelled  testicle  from 
gonorrhoea.  The  less  common  combination  is  inflammation  of  the 
epididymis  and  testis,  in  which  case  the  tunica  vaginalis  is  very  apt  to 
be  affected,  with  perhaps  a  limited  invasion  of  the  vas  deferens. 

As  regards  the  date  of  the  onset  of  swelled  testicle,  it  may  be  said 
that  within  the  first  three  weeks  of  gonorrhoea  the  testis  is  attacked  in 
the  majority  of  cases,  and  that  between  the  fourth  and  sixth  weeks, 
inclusive,  it  is  attacked  rather  less  frequently. 

Double  epididymitis  sometimes  occurs,  in  which  case  usually  the 
second  testis  is  attacked  from  one  to  three  weeks  after  the  first  one.  In 
some  cases,  however,  the  second  testicle  is  not  involved  until  later — 
eight,  ten,  or  even  twelve  weeks.  An  epididymis  or  testis  once  the  seat 
of  gonorrhoeal  inflammation  is  thereafter  very  liable  to  be  affected  with 
each  repetition  of  the  infection,  and  also  when  a  chronic  deep  urethral 
inflammation  undergoes  an  exacerbation  and  an  acute  condition  results. 
Further  than  this,  mechanical  injury,  overexertion,  undue  pressure  on 
the  testis,  may  for  years  after  light  up  a  more  or  less  severe  recrudes- 
cence. 

Cases  have  been  reported  in  which  epididymis  developed  from  three 
to  ten  days  before  the  appearance  of  the  urethral  discharge.  These 
cases  used  to  be  looked  upon  as  curiosities,  and  the  pathological  condi- 
tions underlying  them  were  not  clearly  grasped.  Their  pathogenesis, 
however,  is  not  difficult  of  explanation.  In  all  such  cases  there  has 
been  a  previous  antecedent  gonorrhoea  which  has  left  a  latent  posterior 
urethritis.       In    sexual    and    alcoholic    excesses    this    latent    condition 


EPIDIDYMITIS  AND  EPIDIDYMO-ORCHITIS.  115 

becomes  an  acute  one,  and  for  some  reason,  perhaps  anatomical,  the 
phlegmasia  travels  through  the  ejaculatory  duct  into  the  testis  before 
it  spreads  forward  and  invades  the  anterior  urethra. 

Symptoms. — Before  the  onset  of  the  affection  the  urethral  discharge 
usually,  but  not  always,  ceases,  and  patients  complain  of  varying  symp- 
toms. In  some,  pain  in  the  groin,  at  the  external  ring,  and  along  the 
vas  deferens,  either  in  the  external  or  in  the  pelvic  segment,  is  com- 
plained of.  In  somewhat  rare  cases  pain  is  experienced  in  the  whole 
length  of  the  vas  deferens.  Some  patients  even  complain  of  a  pain 
which  reaches  to  the  kidney.  In  some  cases  the  pain  seems  to  be  at 
first  in  the  deep  urethra  or  in  the  seminal  vesicles,  and  these  patients 
sometimes  suffer  from  pollutions  which  may  be  painful  and  bloody. 
In  general,  there  are  no  premonitory  constitutional  symptoms,  but  as 
the  intensity  of  the  inflammation  increases  a  chill  and  fever  of  various 
degrees,  with  malaise,  want  of  appetite,  great  thirst,  a  frequent  desire 
to  urinate,  and  perhaps  constipation,  may  supervene.  As  a  rule,  the 
systemic  reaction  is  not  great,  but  in  very  severe  cases,  and  particularly 
those  in  which  the  vas  deferens  is  involved,  there  may  be  well-marked 
fever  with  all  its  concomitants — namely,  hot  skin,  coated  tongue,  rapid 
pulse,  together  with  nervousness  and  agitation.  In  some  rare  cases 
there  are  nausea  and  vomiting.  The  invasion  of  the  affection  may  be 
prompt  or  slow.  Many  patients  walk  and  attend  to  their  duties  with 
mild  and  bearable  discomfort  for  one  or  more  days  before  they  are 
forced  to  assume  the  recumbent  position.  In  other  cases,  particularly 
those  in  which  one  or  more  exciting  causes  are  active,  the  affection  is 
well  under  way  and  the  patient  on  his  back  within  twenty-four  hours. 
Early  examination  of  a  case  shows  that  the  epididymis,  with  perhaps 
the  vas,  is  swollen  and  painful,  and  that  the  scrotum  over  it  is  some- 
what reddened.  In  some  cases  the  pain  and  swelling  are  confined  to 
the  globus  minor  or  tail  of  the  epididymis,  which  becomes  of  the  size 
of  a  hickory-nut,  and  the  affection  may  thus  be  limited  ;  usually,  how- 
ever, the  body  and  globus  major  or  head  of  the  organ  are  promptly 
involved.  Then  a  large  tumor  is  found  seated  superiorly  and  poste- 
riorly to  the  testis,  and  the  furrow  which  naturally  exists  between  that 
organ  and  the  epididymis  may  be  present  or  it  may  be  obliterated. 
The  shape  of  the  tumor  varies  in  different  cases.  The  epididymis,  be- 
coming enlarged,  may  cover  the  testis  like  a  cap,  or  it  may  grow  longi- 
tudinally and  form  a  semilunar  tumor,  which  rests  on  the  organ  like  a 
crest  on  a  helmet,  the  head  of  the  appendage  reaching  well  forward  and 
the  tail  well  upward.  There  is  also  usually  more  or  less  lateral  expan- 
sion of  it,  sometimes  almost  enveloping  the  testis.  Pressure  on  the 
testis  in  such  a  case  usually  causes  no  pain,  but  when  the  swollen  epi- 
didymis is  held  between  the  thumb  and  forefinger  the  patient  winces 


116  COMPLICATIONS  OF  GONORRHOEA. 

or  cries  out.  While  at  rest  in  the  horizontal  position,  with  the  scrotum 
well  supported,  the  patient  may  be  tolerably  comfortable.  Coincidently 
with  this  inflammation,  the  scrotum  on  the  affected  side  becomes  of  a 
deep,  even  purplish,  red,  very  much  swollen  from  oedema,  and  adherent 
to  the  testis.  Pain  is  at  this  time  severe,  sometimes  almost  unendurable, 
and  continuous,  with  paroxysms  at  night.  Slight  motion  tends  to 
increase  the  patient's  sufferings,  and  pressure  of  the  bedclothes  causes 
agony.  Coincident  involvement  of  the  cord  is  attended  with  a  still 
greater  amount  of  pain,  which  extends  up  to  the  inguinal  canal.  In 
these  very  severe  cases  the  testicle  is  also,  as  a  rule,  the  seat  of  inflam- 
mation. When  the  epididymis  alone  is  inflamed,  the  swelling  is  very 
considerable ;  but  when  it  and  the  testis  are  involved,  it  is  great,  so  that 
a  tumor  the  size  of  a  small  fist  is  formed.  The  testis  will  be  found  to 
be  very  painful  and  tender,  and  a  much  larger  area  of  the  scrotum  will 
become  inflamed,  thickened,  and  of  a  deep  red.  While  at  first  there 
is  only  moderate  and  localized  adhesion  of  the  upper  portion  of  the 
organ  to  the  scrotal  wall,  when  epididymo-orchitis  is  present,  there  is 
adhesion  of  a  large  surface  corresponding  to  the  size  of  the  swollen 
testicle.  In  proportion  as  the  testicular  inflammation  is  great,  the 
tunica  vaginalis  becomes  affected  and  the  seat  of  serous  effusion,  by 
which  the  size  of  the  tumor  is  materially  increased.  With  this  con- 
comitant the  acme  of  the  inflammation  may  be  said  to  be  reached.  The 
patient  then  will  complain  of  pains  in  the  perineum,  in  the  thighs,  the 
groins,  and  the  lumbar  regions.  In  some  cases  patients  complain 
bitterly  of  deep  pelvic  and  rectal  pains,  which  are  due  to  a  complicating 
inflammation  of  the  seminal  vesicles. 

In  the  acute  stage  particularly,  and  also  in  the  period  of  decline  of 
epididymo-orchitis,  examination  of  the  prostate,  and  sometimes  the 
seminal  vesicles,  by  means  of  rectal  touch  will  in  many  cases  reveal 
swelling  and  congestion  of  those  organs,  sometimes  in  their  totality,  and 
again  on  the  side  corresponding  to  the  testicular  inflammation.  Swelled 
testicles  may  exist  in  a  severe  form  from  one  to  five  days  in  untreated 
cases,  when  subsidence  of  the  inflammation  begins.  In  carefully- 
treated  cases  the  intensity  of  the  symptoms  need  not  last  longer  than 
twenty-four  or  thirty  hours.  The  first  symptoms  of  improvement  is 
amelioration  of  the  pain,  and  soon  it  is  noticed  that  the  patient  can 
move  in  bed  with  more  freedom  than  before.  The  redness  and  oedema 
of  the  scrotum  become  less,  and  its  adhesion  gradually  passes  away,  and 
the  swelled  organ  becomes  smaller  and  can  be  more  freely  manipulated. 
The  swollen  epididymis  may  be  quite  clearly  made  out,  the  testis  can 
be  distinctly  felt,  and  if  any  hydrocele  is  present,  it  may  be  detected  by 
palpation  or  perhaps  by  the  light  test.  As  a  rule,  the  course  of  swelled 
testicle  in  bad  cases  occupies  from  ten  to  fourteen  days,  during  which 


EPIDIDYMITIS  AND  EPIDIDYMO-ORCHITIS.  117 

time  the  patient  will  have  been  confined  to  his  bed.  At  the  end  of  this 
time,  though  he  may  go  about,  he  is  far  from  well,  and  should  be  looked 
after  with  the  most  careful  attention.  Unless  removed  by  tapping,  the 
hydrocele  remains  for  a  long  period,  and  while  it  does  the  testis  remains 
swollen  and  tender.  When  there  is  no  hydrocele  the  testis  is  found  to 
become  gradually  smaller  and  softer,  and  soon  the  line  of  demarcation 
between  it  and  the  epididymis  can  be  made  out.  During  this  period  of 
involution  the  epididymis  also  grows  smaller,  but  much  more  slowly, 
and  for  longer  or  shorter  periods  it  is  found  to  be  enlarged  and  indu- 
rated. Its  continuance  in  this  state  is  governed  largely  by  the  duration 
and  intensity  of  the  inflammation.  So  rapid  and  complete  is  the  invo- 
lution of  the  swelling  of  the  epididymis  in  some  cases  that  it  seems 
scarcely  credible ;  in  others  it  is  slow,  occupying  several  months ;  while 
in  others  permanent  enlargement  and  induration  are  left.  In  severe 
cases — luckily,  not  common — the  testis,  tunica  vaginalis,  epididymis, 
and  vas  deferens  are  left  in  a  state  of  induration  and  chronic  subacute 
inflammation. 

In  a  normally-placed  testis  little  difficulty  is  experienced  in  deter- 
mining the  extent  and  localization  of  the  inflammation,  but  it  must  be 
remembered  that  exceptionally  there  exist  malpositions  of  the  epidi- 
dymis, when  confusion  may  occur.  The  most  common  form  of  mal- 
position is  where  the  epididymis  is  placed  anterior  to  the  body  of  the 
testis,  in  which  the  features  observed  in  the  normal  testis  would  be 
reversed.  Then  it  may  be  seated  on  one  side,  either  external  or  inter- 
nal, in  which  event  the  diagnosis  need  not  be  difficult.  In  the  third 
variety  the  epididymis  and  vas  deferens  are  attached  superiorly,  the 
long  axis  of  the  testis  being  in  the  anteroposterior  direction.  In  a 
fourth  variety  the  epididymis  and  vas  deferens  form  a  loop  or  sling 
from  before  backward  around  the  testis.  It  is  always  important  to 
make  a  correct  estimate  of  the  position  of  the  parts,  particularly  if 
puncture  of  the  tunica  vaginalis  is  decided  upon.  It  is  a  good  rule  to 
find  the  vas  deferens  high  up  in  the  scrotum,  and  if  practicable  to  trace 
it  downward  between  the  tips  of  the  thumb  and  fore-finger. 

Sometimes,  even  when  the  epididymis  is  normally  placed,  its  weight 
and  bulk  are  so  much  increased  by  inflammation  that  it  falls  downward 
and  forward  with  the  testis  above  it.  Examination  then  reveals  the 
tail  of  the  epididymis  anteriorly  and  the  head  posteriorly,  the  organ 
hanging  anteroposteriorly  in  the  scrotum.  Then,  again,  owing  to  the 
heaviness  of  the  epididymis,  it  sinks  down  to  the  bottom  of  the  scrotum, 
and  the  testis  then  lies  directly  on  top  of  it. 

Gonorrhoeal  inflammation,  when  it  attacks  an  undescended  or  mis- 
placed testis,  has  frequently  been  unrecognized. 

Gonorrhoeal  inflammation  of  the  vas  deferens  outside  of  the  inguinal 


118  COMPLICATIONS  OF  GONORRHOEA. 

canal,  without  involvement  of  the  corresponding  testis,  is  a  rather  rare 
complication  and  presents  in  the  main  the  symptoms  of  epididymitis. 

Localized  inflammation  of  the  vas  deferens  within  the  pelvis  some- 
times occurs,  and  causes  much  deep-seated  pain  during  acute  gonorrhoea. 
In  some  cases  the  swelling  can  be  made  out  by  physical  examination. 
In  other  cases  the  swelling  is  inaccessible,  but  the  history  of  the  case 
and  the  symptoms  point  to  involvement  of  the  vas.  Sometimes  the 
surgeon  suspects  the  case  to  be  one  of  intrapelvic  abscess. 

Induration  of  the  epididymis  following  gonorrhoea!  inflammation 
may  be  limited  to  the  tail,  to  the  head,  or  may  involve  the  whole 
appendage.  In  some  cases  it  is  absorbed,  and  in  others  it  remains 
permanently.  It  sometimes  feels  like  a  little  mass  of  firm  structure  of 
roundish  or  ovoid  shape  when  seated  at  either  head  or  tail.  In  general, 
the  swelling  is  not  very  large,  but  it  may  remain  for  a  long  period 
localized  to  the  head,  and  be  nearly  as  large  as  the  testis.  In  some 
cases,  when  the  whole  epididymis  is  chronically  indurated,  it  forms  a 
half-moon-shaped  mass  whose  bulk  is  greater  than  that  of  the  gland. 
The  most  frequent  form  of  induration  of  the  epididymis  is  that  in 
which  the  part  is  about  as  thick  as  a  lead  pencil  or  a  peanut.  It  is 
hard  to  say  which  is  the  more  frequently  found — induration  of  the  head 
or  the  tail  of  the  epididymis.  Hard  enlargement  of  the  whole  append- 
age is  less  common  than  the  localized  induration. 

The  surface  of  simple  gonorrhoeal  induration  of  the  epididymis  is 
usually  smooth  or  of  rounding  or  waving  outline,  in  marked  contrast  to 
the  nodulated  and  angular  feel  of  tubercular  epididymitis.  In  chronic 
syphilis  the  epididymis  is  sometimes  enlarged  in  whole  and  in  part,  and 
the  general  outline  of  the  swelling  is  much  like  that  of  the  gonorrhoeal 
affection. 

The  fact  that  induration  of  the  epididymis  may  lead  to  occlusion  of 
the  seminiferous  ducts  emphasizes  the  necessity  for  prompt  and  vigorous 
treatment. 

Abscess  of  the  testis  is  a  not  frequent  complication  of  gonorrhoeal 
epididymo-orchitis,  the  focus  of  the  trouble  being  usually  in  the  epididy- 
mis. In  these  cases  of  abscess  of  the  epididymis  or  testis  following 
gonorrhoea  a  suspicion  of  tuberculosis  is  warranted,  and  the  patient 
should  be  well  looked  after  and  placed  in  the  best  of  hygienic  conditions. 
Cysts  in  the  epididymis  sometimes  follow  swelled  testis,  and  are  some- 
times the  seat  of  acute  pain,  and  may  be  mistaken  for  circumscribed 
abscesses. 

Abscess  of  the  body  of  the  testis  somewhat  rarely  occurs  during 
gonorrhoeal  epididymo-orchitis  and  it  may  lead  to  fungus  and  hernia 
testis. 

Gangrene  of  the  scrotum  is  a  rare  complication,  and  it  usually  begins, 


EPIDIDYMITIS  AND  EPIDIDYMO-ORCHITIS.  119 

particularly  in  cases  which  have  been  poulticed,  at  a  dependent  portion 
of  the  sac  as  a  black  spot,  which  spreads  and  destroys  more  or  less  of 
the  walls,  laying  bare  the  testis  or  testes,  which,  however,  are  not 
invaded.  After  the  cessation  of  the  gangrene  the  parts  usually  heal 
and  cover  the  organs  again,  unless  the  destruction  has  been  very  exten- 
sive.    Gangrene  of  the  scrotum  may  follow  gangrene  of  the  testis. 

Neuralgia  is  a  not  uncommon  sequela  of  swelled  testicle.  It  may 
exist  as  a  slightly  painful  sensitiveness  of  the  organ  and  along  the  cord, 
particularly  on  pressure  or  during  active  motion,  or  as  a  rather  dull 
pain  subject  to  irregular  and  fugitive  paroxysms.  Usually,  in  these 
cases  the  epididymis  is  found  to  be  enlarged  and  very  sensitive.  It  is 
commonly  seen  in  weak,  sickly  subjects,  particularly  those  of  neuropathic 
tendency,  and  subjects  given  to  worry  and  fretting. 

Reflex  neuralgias  are  not  infrequent  complications  and  sequelae  of 
swelled  testicle.  The  pain  is  generally  unilateral  and  confined  to  the 
territory  supplied  by  the  lumbar  and  sacral  nerves  of  the  affected  side, 
but  may  cross  the  median  line  and  extend  in  various  directions. 

Patients  who  have  suffered  from  epididymitis,  particularly  those  in 
whom  relapses  have  been  frequent  and  whose  epididymes  are  thickened, 
are  prone  to  engorgement  and  gummatous  infiltration  of  these  parts  if 
they  subsequently  contract  syphilis.  The  same  tendency  is  observed  in 
cases  in  which  the  testis  proper  has  been  inflamed  during  gonorrhoea. 
Chronically  inflamed  and  indurated  epididymes  sometimes  become  the 
seat  of  caseous  degeneration,  and  in  sickly,  scrofulous,  and  tuberculous 
subjects  tuberculosis  may  attack  them. 

Atrophy  of  the  testis  has  been  known  to  occur  in  a  few  cases  follow- 
ing orchiepididymitis,  and  hypertrophy  is  not  very  uncommon,  particu- 
larly in  subjects  who  have  had  repeated  attacks  of  the  affection. 

Chronic  hydrocele  is  frequently  caused  by  swelled  testicle. 

Causes  of  Epididymitis  and  Epididymo-orchitis.  —  Gonorrhoea 
being  the  predisposing  cause,  various  exciting  causes  are  often  the 
starting-points  of  the  trouble.  These  are  the  early  use  of  strong  injec- 
tions, particularly  when  used  to  abort  the  disease,  and  the  precocious 
administration  of  copaiba,  cubebs,  and  oil  of  santal ;  indulgence  in 
alcoholic  stimulants  ;  and  sexual  excitement,  with  or  without  coitus, 
since  men,  either  from  lust  or  with  a  mistaken  idea  that  they  may  thus 
rid  themselves  of  their  trouble,  often  have  connection  while  suffering 
from  gonorrhoea.  In  the  majority  of  cases,  walking,  activity  in  busi- 
ness, lifting  heavy  weights,  pulling  violently,  dancing,  and  riding,  par- 
ticularly on  horseback,  bicycling,  skating,  are  the  immediate  causes. 
Passage  of  sounds  and  catheters  toward  the  decline  of  gonorrhoea  is 
frequently  followed  by  epididymitis.  Consequently,  such  instrumenta- 
tion should  not  be  adopted  in  the  declining  stage  of  gonorrhoea,  or  when 


120  COMPLICATIONS  OF  GONORRHOEA. 

stricture  of  the  urethra  is  followed  by  a  mild  and  ephemeral  epididy- 
mitis or  epididymo-orchitis. 

Diagnosis. — Commonly,  no  difficulty  is  experienced  in  the  diagnosis 
of  swelled  testicle,  since  the  history  of  the  case  and  the  nature  of  the 
lesion  are  so  clear.  In  those  rare  cases  of  acute  hydrocele  doubt  might 
exist,  but  it  would  be  soon  dispelled  by  a  consideration  of  the  history 
of  the  case  and  an  examination  of  the  parts.  Swelled  testicle,  with 
redness  and  oedema  of  the  scrotum,  is  said  to  have  been  mistaken  for 
erysipelas  of  that  pouch.  Such  an  error  will  rarely  occur,  and  with 
ordinary  care  will  be  promptly  found  out.  Hematocele  of  the  tunica 
vaginalis  may  at  first  resemble  gonorrheal  swelled  testicle,  but  the  his- 
tory of  traumatism  will  settle  the  question.  The  same  remarks  apply 
to  orchitis  of  traumatic  origin. 

In  epididymo-orchitis,  or  epididymitis  accompanied  by  inflammation 
of  the  cord  as  far  as  the  external  ring,  a  mistaken  diagnosis  of  hernia 
may  be  made,  particularly  when  there  is  much  fever,  with  constipation 
and  vomiting,  as  sometimes  occurs.  The  error  need  not  be  of  long  dura- 
tion, since  in  the  scrotal  lesion  there  is  a  history  of  gonorrhoea,  while  in 
hernia  there  is  usually  a  history  of  a  fugitive  or  permanent  tumor  in  the 
groin,  and  perhaps  of  antecedent  inflammation  or  strangulation  of  the 
hernial  sac. 

Epididymitis  of  a  misplaced  or  undescended  testis  sometimes  is  dif- 
ficult of  recognition.  In  such  cases  the  history  of  a  urethral  discharge 
should  cause  suspicion,  when  the  examination  of  the  scrotum  will  show 
absence  of  one  testis.  It  must  be  remembered  that  the  testis  may  be 
retained  within  the  abdominal  cavity,  in  the  inguinal  canal,  and  that  it 
may  be  found  in  the  perineum. 

In  all  cases  it  is  of  importance  to  assure  one's  self  of  the  relation  of 
the  epididymis  to  the  testis,  since  puncture  of  the  tunica  vaginalis  is  so 
frequently  necessary.  It  is  important  to  ascertain  whether  inversion  of 
the  epididymis  is  present,  since  puncture  under  these  circumstances 
might  wound  or  destroy  the  vas  deferens.  In  swelled  testicle  the  seat 
of  inversion  the  tumor  is  long  anteroposteriorly,  with  the  epididymis 
well  forward  and  the  testis  under  and  rather  behind  it. 

In  cases  of  inflammation  of  the  vas  deferens  it  is  well  to  seek  it  as  it 
leaves  the  tail  of  the  epididymis,  and  trace  it  until  it  will  be  found  to 
be  lost  in  the  swollen  meshes  of  the  cord,  since  it  may  not  be  possible 
to  examine  it  as  it  escapes  from  the  canal.  The  diagnosis  of  these  cases 
is  more  difficult  when  the  portion  of  the  cord  between  the  external  and 
internal  rings  is  also  swollen. 

Prognosis. — The  prognosis  of  swelled  testicle  from  gonorrhoea  is,  in 
the  main,  good,  since  more  or  less  complete  resolution  generally  occurs. 
It  depends,  however,  largely  upon  the  promptness  and  efficiency  of  the 


EPIDIDYMITIS  AND  EPIDIDYMO-ORCHITIS.  121 

treatment  and  on  the  nature  of  the  patient.  Careless  habits,  intolerance 
of  restraint,  and  poor  fibre  tend  to  make  the  prognosis  more  serious. 
The  occurrence  of  the  various  structural  complications  already  detailed, 
and  the  supervention  of  the  various  neuralgias,  of  course  make  the 
condition  more  serious.  The  fecundity  of  a  man  is  not  imperilled  by 
induration  of  one  epididymis  and  the  occlusion  of  its  vas  deferens,  but 
the  total  occlusion  of  both  of  these  ducts  renders  him  sterile.  Though 
his  procreative  power  is  lost,  his  ability  to  copulate  remains.  The  ques- 
tion of  the  sterility  of  a  man  often  becomes  an  important  matter  in  do- 
mestic relations.  It  must  not  be  stated  without  absolute  positiveness  that 
when  no  spermatozoa  are  found  in  the  semen  a  man  is  absolutely  sterile, 
since  it  may  be  that  there  is  present  a  temporary  stenosis  due  to  exuda- 
tion, and  for  the  reason  that  under  treatment  resolution  of  the  infiltra- 
tion may  be  produced.  It  is  only  in  cases  where  the  semen  examined 
over  long  periods  is  found  to  be  wanting  in  spermatozoa  that  the  exist- 
ence of  absolute  sterility  may  be  asserted. 

The  prognosis  is  always  better  when  the  lesion  is  seated  in  the  head 
of  the  epididymis,  and  correspondingly  worse  when  in  the  tail,  since  in 
that  event  the  spermatic  vessels  have  converged  to  form  one  tube — the 
vas  deferens.  Since  relapses  of  epididymitis  frequently  have  their 
origin  in  chronic  subacute,  deep-seated  urethral  inflammation,  their 
occurrence  will  suggest  the  necessity  of  the  removal  of  the  cause. 
Apart  from  the  varying  conditions  of  the  morbid  process  as  influencing 
the  prognosis,  the  latter  largely  depends  on  the  treatment  of  the  tes- 
ticular disorder  in  its  declining  and  chronic  stages.  If  in  these  periods 
active  conservative  treatment  is  followed,  full  resolution  may  be  ob- 
tained in  the  majority  of  cases. 

Treatment. — Absolute  rest  in  bed  is  the  first  indication  in  the  treat- 
ment of  the  severe  form  of  gonorrhoeal  epididymitis.  The  next  indica- 
tion is  to  place  the  swollen  organ  in  a  position  of  rest  and  comfort ;  and 
for  this  the  suspensory  bandage  is  generally  useless.  A  number  of 
excellent  procedures  are  at  our  command.  The  simplest  is  to  form  an 
immovable  platform  or  shelf  on  which  the  organ  may  rest.  This  may 
be  done  with  India-rubber  adhesive  plaster ;  and  though  regarded  as 
dirty  and  objectionable  by  some,  it  by  a  little  trouble  can  be  made 
cleanly  and  serviceable.  A  sufficiently  long  strip  of  adhesive  plaster, 
three  to  five  inches  wide,  is  placed  across  the  thighs  of  the  recumbent 
patient  so  high  up  that  its  superior  border  touches  his  perineum,  whose 
scrotum  for  the  moment  has  been  carefully  lifted  toward  the  body. 
While  sufficient  adhesive  surface  is  applied  to  the  thighs,  that  portion 
of  the  plaster  which  forms  the  bridge  between  them  may  be  covered 
with  gutta-percha  tissue,  which,  being  folded  under,  adheres  to  the 
adhesive  plaster.     Another  efficient  method  requires  a  soft  linen  or  silk 


122  COMPLICATIONS  OF  GONOBRHCEA. 

handkerchief,  which  should  be  folded  diagonally  so  as  to  form  a  tri- 
angle, in  the  centre  of  the  base  of  which  two  pieces  of  tape  are  to  be 
sewn.  Having  placed  a  firm  waistband  around  the  body  just  above  the 
iliac  crests,  the  scrotum  is  elevated  and  the  centre  of  the  base  of  the 
handkerchief  triangle  is  placed  in  accord  with  the  raphe  of  the  scrotum. 
The  tapes  are  carried  around  the  thighs  on  either  side,  and  are  secured 
by  the  waistband  near  the  iliac  crests.  Having  thus  rendered  the  band- 
age firm,  the  two  outer  ends  of  the  handkerchief  are  brought  upward  along 
the  folds  of  the  groin  and  secured  to  the  waist-bandage,  while  the  apex 
of  the  handkerchief  triangle  is  brought  upward  in  the  median  line  and 
also  secured  to  the  band.  By  these  means  the  testes  may  be  kept  at 
rest  and  any  form  of  application  may  be  used. 

What  is  known  among  athletes  and  actors  as  the  jock-strap  is  also 
very  useful  in  cases  of  swelled  testicle  either  when  the  patient  is  in  bed 
or  on  foot. 

The  scrotum  may  also  be  supported  by  a  wad  of  oakum  or  absorbent 
cotton  placed  between  the  thighs. 

The  next  indication  is  to  administer  a  brisk  cathartic  in  the  form  of 
pills  or  a  powder  of  from  five  to  ten  grains  of  calomel  and  bicarbonate 
of  soda.  The  diet  must  be  mild  and  sparing,  preferably  of  milk  or  of 
toast  and  weak  tea.  Little  internal  medication  is  necessary,  though  the 
mixture  of  bicarbonate  of  potassa  with  tincture  of  hyoscyamus  may  be 
given. 

In  some  severe  cases  a  goodly  number  of  leeches  may  be  applied  to 
the  groin  as  far  down  as  the  scrotum. 

For  the  relief  of  pain,  particularly  at  night,  some  preparation  of 
opium  may  be  used  in  the  form  of  pill,  suppository,  or  hypodermic 
injection.  Salicylate  of  soda  has  been  exploited  as  a  valuable  remedy 
in  these  cases,  but  it  has  failed  utterly  in  my  hands  to  comfort  the 
patient  or  affect  the  phlegmasia  in  any  way. 

In  general,  a  strong  lead-and-opium  wash,  perhaps  combined  with 
muriate  of  ammonia,  and  applied  to  the  organ  properly  fixed  on  old 
linen  or  lint,  or  absorbent  cotton  or  gauze,  is  a  most  efficient  and  reliable 
remedy.  At  the  onset  of  the  affection  ice,  guardedly  applied,  may  be 
used.     For  this  purpose  an  ice-bag  may  be  employed. 

In  some  cases  cold  applications  are  not  grateful,  and  in  them  hot 
tobacco  poultices  will  prove  very  efficacious. 

The  following  ointments  are  often  of  service  when  spread  thickly 
on  lint : 

1^.  Pulv.  opii,  3ij  ; 

Pulv.  cam  ph.,  3ss  ; 

Vaseline  or  glycerini,  3J. — M. 


EPIDIDYMITIS  AND  EPIDIDYMO-ORCHITIS.  123 

And 

Ity.  Pulv.  opii, 

Palv.  amyli,  ad  §j  ; 

Glycerini,  q.  s. 

Ft.  paste  of  the  thickness  of  tar. 

When  the  intensity  of  the  inflammation  is  on  the  wane,  due  to  the 
use  of  either  heat  or  cold,  a  more  radical  treatment  may  be  followed. 
Every  effort  must  be  made  to  cure  the  inflammation  of  the  deep  ure- 
thra. One  of  the  most  beneficial  is  the  application  at  white  heat  of 
Paquelin's  cautery  over  the  scrotum  corresponding  to  the  swelled  tes- 
ticle. The  parts  must  first  be  shaved  and  thoroughly  washed.  The  tip 
of  the  cautery  may  then  be  applied  rapidly  and  but  for  a  second  or  two 
in  ten  or  twelve  spots  well  separated  from  each  other.  The  scrotum  is 
then  to  be  enveloped  in  absorbent  cotton  and  put  in  a  comfortable  band- 
age. The  cautery  may  be  used  every  two,  three,  or  four  days.  The 
effect  will  usually  be  promptly  seen  in  the  amelioration  of  the  symptoms 
and  the  subsidence  of  the  swelling. 

Very  much  benefit  and  comfort  can  be  obtained  by  the  aseptic  with- 
drawal of  fluid  from  the  cavity  of  the  tunica  vaginalis  by  means  of  a 
hypodermic  syringe  just  as  soon  as  it  can  be  done. 

Another  method  of  treatment  in  the  declining  stage  is  the  applica- 
tion every  day  or  two  of  a  solution  of  nitrate  of  silver  (60  or  120  grs. 
to  the  ounce  of  water).  The  whole  of  the  affected  side  is  painted  and 
the  parts  treated  as  directed  after  the  cautery  treatment. 

In  subacute  and  chronic  cases  an  ointment  composed  of  guaiacol  and 
vaseline  (10  or  15  to  100)  may  be  used.  Ichthyol  ointment,  20  to  100, 
may  cause  resolution  of  the  induration. 

Strapping  the  testicle  is  never  appropriate  in  the  acute  stage,  though 
it  may  be  beneficial  in  some  cases  of  chronic  swelled  testicle.  It  is 
much  less  commonly  employed  now  than  formerly,  owing  to  the  fact 
that  it  is  difficult  of  application,  is  not  cleanly,  loosens  quickly,  and 
often  gives  rise  to  fissures  and  inflammation  of  the  skin.  The  scrotum 
must  be  smoothly  shaved  before  the  plaster  is  applied.  Mercurial, 
belladonna,  or  the  plain  rubber  adhesive  plaster  may  be  used  in  strips 
of  three-quarters  of  an  inch  in  width. 

Another  method  of  strapping  is  carried  out  as  follows  :  the  testis  is 
grasped,  around  its  upper  portion  a  ring  of  adhesive  plaster  is  fixed,  and 
covered  over  with  a  piece  of  silk  handkerchief,  over  which  is  a  thick 
layer  of  absorbent  cotton,  and  over  that  again  a  layer  of  gutta-percha 
tissue.  Then  over  the  whole  strips  of  adhesive  plaster  are  passed  in  a 
circular  manner,  so  that  the  ends  may  be  drawn  more  or  less  tightly 
before  being  fixed.     About  every  twenty-four  hours  it  is  necessary  to 


124  COMPLICATIONS  OF  GONORRHOEA. 

tighten  the  adhesive  strips.  Removal  of  fluid  from  the  tunica  vaginalis 
is  especially  necessary  in  all  cases  before  compression  is  applied. 

In  those  extremely  severe  but  quite  rare  cases  in  which  the  testis  is 
also  inflamed,  together  with  serous  effusion  in  the  tunica  vaginalis, 
prompt  puncture  of  the  sac  is  urgently  called  for,  and  is  commonly 
followed  by  marked  relief  of  the  pain  and  tension  in  the  organ.  It  is 
well  to  employ  a  small  straight  bistoury,  and  to  make  a  number  of 
minute  punctures  well  down  into  the  cavity  of  the  tunica  vaginalis, 
over  its  median  and  most  rounded  portion,  taking  care  that  the  tunica 
albuginea  is  not  wounded.  When  practicable,  in  these  cases  withdrawal 
of  the  fluid  by  the  hypodermic  syringe  may  be  done. 

The  treatment  of  neuralgia  of  the  testis  following  gonorrhoea,  or 
indeed  any  morbid  process,  should  be  directed  primarily  to  the  affected 
part.  Blisters  with  cantharidal  collodion  may  produce  much  benefit. 
Paquelin's  cautery  and  the  various  stimulating  applications  already 
detailed  may  be  used.  Opium  and  belladonna  ointment  may  also  be 
of  service,  according  to  the  symptoms.  If  any  thickening  of  the  epi- 
didymis or  cord  can  be  made  out,  it  should  receive  energetic  treatment 
on  the  lines  followed  in  treating  induration  of  the  epididymis.  In  every 
case  the  condition  of  the  deep  urethra  should  be  ascertained,  and  if  any 
inflammation  be  found,  it  should  be  treated.  Any  general  morbid  con- 
dition should  be  carefully  considered,  and  proper  medication  and  hygiene 
should  be  instituted. 

Induration  of  the  epididymis  and  enlargement  of  the  testis,  which 
sometimes  follow  gonorrhoea  or  other  morbid  processes,  require  some  of 
the  foregoing  methods  of  treatment.  Stimulation  and  compression  are 
especially  indicated.  Strapping  the  testis  and  the  use  of  the  other  com- 
pressing agents  should  be  employed.  In  some  cases  benefit  follows  the 
synchronous  use  of  iodine  or  iodide-of-lead  ointment.  In  some  cases  of 
chronic  induration  of  the  testis  and  epididymis,  not  due  to  syphilis,  mer- 
curial ointment  with  compression  will  produce  resolution.  Then,  again, 
I  have  seen  great  benefit  follow  the  combined  use  of  mercurial  ointment 
and  the  mixed  treatment,  though  the  induration  was  wholly  due  to  gon- 
orrhoea, and  not  even  remotely  to  syphilis.  In  obstinate  cases  it  is 
always  well  to  try  this  combination  treatment.  In  all  cases  of  swelled 
testicle  it  is  necessary  to  cure  the  coexisting  posterior  urethritis. 

GONORRHEAL   RHEUMATISM. 

The  term  "gonorrheal  rheumatism"  is  applied  to  a  complex  inflam- 
mation, chiefly  of  the  joints,  fasciae,  bursse,  and  tendinous  sheaths,  and 
also  of  the  eye  and  fibrous  tissues,  which  follows  in  the  course  of 
urethral  gonorrhoea  and  gonorrhoea!  vulvitis,  vaginitis,  and  conjunctiv- 
itis.    It  sometimes  complicates  urethral  suppuration  caused  by  instru- 


GONORRHEAL  RHEUMATISM.  125 

mentation,  even  as  simple  as  the  passage  of  a  sound.  This  form  of 
rheumatism  does  not  complicate  balanitis  or  simple  inflammations  of 
the  external  genitals  of  the  male  or  female. 

Gonorrheal  rheumatism  attacks  men  more  frequently  than  women, 
and  is  seen  in  infants  and  in  the  young  and  the  old.  It  has  no  etiolog- 
ical relation  to  a  pre-existent  rheumatic  condition  or  diathesis,  for  the 
reason  that  we  see  many  truly  rheumatic  subjects  who  may  surfer  from 
gonorrhoea  without  becoming  affected  with  its  rheumatism.  This  affec- 
tion may  follow  each  attack  of  gonorrhoea,  but  such  a  course  is  far  from 
being  the  invariable  rule,  since  many  men  have  thus  suffered  once  after 
gonorrhoea,  and  never  again  after  subsequent  infections. 

The  inflammatory  process  in  gonorrhceal  rheumatism  is  caused  by 
the  gonococcus  and  its  toxins,  but  the  morbid  condition  may  be  further 
complicated  and  aggravated  by  the  concurrent  or  subsequent  action  of 
pyogenic  microbes.  Whether  the  cases  presenting  ordinary  serous 
effusion  are  due  to  the  gonococcus  alone  or  its  toxic  products,  and 
whether  the  cases  of  articular  and  fibrous-tissue  abscesses  are  due  to  the 
action  of  the  gonococcus,  aided  by  that  of  pus-microbes,  we  cannot 
to-day  state  with  scientific  precision.  The  results  of  observation  seem, 
however,  to  show  that  when  the  joint-effusion  is  serous  or  serofibrinous 
the  gonococcus  is  found  in  it,  and  that  when  it  is  seropurulent  or  puru- 
lent pyogenic  microbes  are  found.  There  seems  to  be  sufficient  evi- 
dence at  hand  to  warrant  the  statement  that  in  many  cases  the  pyogenic 
microbes  dominate  in  the  phlegmasia,  and  thus  the  gonococci  perish  in 
whole  or  in  part. 

It  is  very  difficult  to  state  definitely  the  date  of  the  onset  of  gonor- 
rhceal rheumatism.  Though  we  have  not  absolute  knowledge  on  the 
subject,  it  is  probable  that  absorption  of  septic  material  does  not  take 
place  until  the  infection  has  reached  the  posterior  urethra.  It  is  usually 
in  the  older  and  more  chronic  cases  of  gonorrhoea  that  its  rheumatism 
appears ;  consequently  we  more  frequently  see  it  develop  in  one,  two, 
three,  and  four  months  after  the  beginning  of  the  infection,  and  even 
later. 

Besides  the  joints,  other  structures  are  frequently  involved  in  gonor- 
rhoeal  rheumatism,  either  in  combination  with  the  joint-lesions  or  as 
special  inflammations.  The  bursa?  are  quite  frequently  attacked.  The 
bursa  in  front  of  the  tendo  Achillis  and  the  one  beneath  the  os  calcis 
are  most  frequently  involved,  while  those  of  the  wrist,  ankle,  the  patella, 
the  tuber  ischii,  the  bicipital,  and  of  the  psoas  muscle  are  less  commonly 
attacked.  The  tendinous  sheaths  may  be  affected  in  gonorrhceal  rheu- 
matism, either  alone  or  in  combination  with  joint-lesions.  The  sheaths 
most  commonly  the  seat  of  the  inflammation  are  the  extensors  of  the 
hands  and  fingers,  the  dorsal  flexors  of  the  toes  and  the  flexor  pollicis, 


126  COMPLICATIONS  OF  GONORRHOEA. 

the  sheaths  of  the  biceps  brachii,  and  of  the  tenclo  Achillis.  The 
external  fibrous  structures  and  ligamentous  tissues  of  joints,  particularly 
the  large  ones  of  the  knee  and  the  elbow,  are  not  infrequently  involved 
by  this  form  of  rheumatism,  which  is  called  periarticular  gonorrhoeal 
rheumatism.  This  may  also  be  said  of  smaller  joints,  such  as  of  the 
hands,  feet,  and  toes.  In  these  cases  there  is  no  intra-articular  phleg- 
masia. The  plantar  and  palmar  fascia  are  quite  rarely  the  seat  of 
gonorrhoeal   inflammation. 

The  essential  lesion  of  the  joints  is  an  inflammation  of  their  synovial 
membrane,  which  may  result  in  serous  synovitis,  serofibrinous  syno- 
vitis, seropurulent  synovitis,  which  are  the  more  common  forms,  and 
purulent  synovitis,  which  is  quite  rare.  Gonorrhoeal  rheumatism  is 
essentially  an  hydrarthrosis,  and  in  very  many  instances  the  disease  is 
confined  to  the  synovial  membrane  of  the  joint  during  the  whole  course 
of  the  affection. 

In  some  cases  the  discharge  ceases  when  the  rheumatism  begins  ;  in 
others  it  is  increased  before  its  onset,  and  in  still  other  cases  there  is  no 
alteration  in  its  course. 

Acute  inflammation  of  one  joint,  particularly  of  the  knee,  and  called 
gonitis,  is  the  most  common  form  of  gonorrhoeal  rheumatism.  This 
form  is  called  acute  monoarticular  gonorrhoeal  rheumatism.  In  this 
affection  there  may  be  no  premonitory  symptoms  whatever,  and  the 
patient's  first  complaint  will  be  that  his  joint  is  rather  painful  and  that 
he  limps  slightly.  In  other  cases  there  is  a  slight  chill  and  fugitive 
pains  over  the  body,  with  malaise  and  mild  fever.  These  symptoms 
usher  in  the  hydrarthrosis.  In  more  severe  cases  these  symptoms  are 
much  accentuated.  Cases  occur  in  which  there  is  mild  delirium,  with 
a  condition  resembling  typhoid  fever  in  its  third  week.  Again,  there 
are  rare  cases  in  which  the  patient  is  stupid,  dull,  heavy,  and  very 
feverish  (temp.  102°  to  105°  Fahr.),  and  presents  the  appearance  of 
profound  septic  intoxication.  The  symptoms  may,  therefore,  be  very 
mild,  quite  severe,  and  exceptionally  very  severe  and  even  grave  in 
character.  The  acme  of  the  constitutional  symptoms  is  generally 
reached  within  a  week,  and  from  that  time  onward  they  range  in  about 
the  same  degree  of  mildness  or  severity.  Sweating,  so  common  and  so 
copious  in  ordinary  rheumatism,  is  not  observed  to  any  marked  extent 
in  the  form  under  consideration. 

In  general  terms,  it  may  be  stated  that  the  symptoms  are  rather 
mild  in  cases  of  serous  effusion,  rather  more  severe  when  the  effusion  is 
serofibrinous,  and  most  severe  when  it  is  seropurulent  or  purulent. 

The  pain  in  the  joint  is  at  first  slight,  but  it  speedily  increases  in 
intensity,  particularly  if  the  patient  continues  to  go  about.  The  evi- 
dences of  serous  effusion  into  the  joint  are  soon  seen.     If  the  knee-joint 


GONORRHEAL  RHEUMATISM.  127 

is  affected,  the  patella  is  soon  elevated  above  the  level  of  the  femur,  and 
two  fluctuating  cushions  may  be  seen  on  each  side  of  its  upper  portion 
and  over  the  lower  extremity  of  the  femur,  and  two  similar  ones  on  each 
side  of  its  lower  portion  over  the  head  of  the  tibia.  The  patella  floats 
in  the  fluctuating  cushion,  and  if  pressed  downward  it  rebounds  with  a 
distinct  click.  With  the  onset  of  the  effusion  heat,  redness,  and  swell- 
ing are  observed  in  the  investing  integument.  In  many  acute  cases 
there  is  no  perceptible  thickening  in  the  fibrous  structures  around  the 
joint.  In  the  chronic  form  this  extra-articular  condition  may  be 
observed.  In  the  acme  of  the  affection  the  joint  is  much  enlarged  and 
distended,  the  skin  is  red  and  tense,  and  there  is  pain  which  may  be 
dull  and  continuous  or  throbbing  and  stabbing.  In  many  cases  the 
pain  is  worse  at  night.  As  the  phlegmasia  in  the  joint  increases  the 
limb  becomes  more  and  more  immobile. 

This  monoarticular  form  of  gonorrhoeal  rheumatism  may  constitute 
the  whole  affection,  but  in  some  cases  other  joints  become  involved. 
When  the  disease  thus  spreads,  there  is  no  abatement  of  the  morbid 
process  in  the  joint  first  affected,  but  there  may  be  an  intensification  of 
the  general  symptoms.  Under  favorable  circumstances  the  acute  dropsy 
of  the  joint,  in  the  monoarticular  form,  subsides  in  from  four  to  six 
weeks,  but  if  the  morbid  process  is  more  severe  and  the  exudates  are 
serofibrinous,  seropurulent,  or  purulent,  then  the  duration  is  much 
longer — we  may  say  indefinite. 

Monoarticular  gonorrhoeal  rheumatism,  also  called  gonocele,  may 
begin  in  a  slow  and  subacute  manner,  and  may  then  develop  into  a 
chronic  affection.  In  this  event  the  patient  experiences  very  little  pain, 
and  only  some  inconvenience  in  walking  and  moving  the  joint.  Sooner 
or  later  he  discovers  that  the  joint  is  enlarged  and  the  seat  of  serous 
effusion.  There  is  no  extra-articular  inflammation  and  no  general  sys- 
temic reaction.  In  this  condition  the  joint  may  remain  for  many 
months.  In  some  cases  visible  improvement  may  be  noted,  which  is 
usually  followed  by  an  exacerbation  of  a  low  grade.  In  this  way  the 
case  may  hitch  and  halt  until  inflammatory  changes  in  the  synovial 
membrane  and  articular  surface,  and  even  the  bones,  are  developed  and 
arthritis  deformans  results. 

The  less  common  form  of  gonorrhoeal  rheumatism  is  that  in  which, 
as  a  general  rule,  two  or  three,  and  exceptionally  many,  joints  are 
involved,  and  it  is  called  polyarticular  acute  gonorrhoeal  rheumatism. 
The  symptom-complex  of  this  form  resembles  that  of  the  monoarticular 
form.  The  course  of  this  joint-affection,  however,  is  different.  Some- 
times during  the  course  of  the  inflammation  in  the  first  joint  a  second 
one  is  attacked,  but  there  is  usually  no  marked  amelioration  in  the  con- 
dition of  the  first.     AVith  each  joint-involvement  the  symptoms  may 


128  COMPLICATIONS  OF  GONORRHOEA. 

undergo  an  exacerbation,  which  is  soon  followed  by  a  remission ;  and 
thus  the  case  progresses  until  several  or  many  joints  are  involved. 
Usually  the  number  of  joints  involved  is  not  as  great  as  in  articular 
rheumatism.  I  have,  however,  seen  a  case  in  which  every  joint  of  the 
body,  even  the  temporomaxillary  articulation,  was  thus  involved,  and 
as  a  result  became  ankylosed. 

In  this  form  also  there  is  usually  not  the  painful  thickening  of  the 
fibrous  tissues  around  the  joint  which  is  such  a  marked  feature  of  artic- 
ular rheumatism.  The  disproportion  between  the  general  symptoms 
and  the  joint-lesions  is  so  marked  in  gonorrheal  rheumatism,  and  in 
such  contrast  with  what  occurs  in  acute  articular  rheumatism,  in  which 
the  symptoms  are  severe  and  striking,  that  the  nature  of  the  complaint 
is  readily  determined. 

The  course  of  this  form  of  rheumatism  depends  largely  on  the 
nature  of  the  effusion  and  of  the  exudates.  If  the  lesion  is  simply  a 
serous  effusion,  the  affection  may  last  two,  three,  or  many  months.  If 
it  is  serofibrinous,  it  may  last  longer ;  and  if  seropurulent  or  purulent, 
the  course  may  be  indefinite. 

Chronic  dropsy  of  the  joint,  more  or  less  disorganization,  and  even 
ankylosis,  may  result.  In  very  chronic  cases  atrophy  of  the  muscles 
connected  with  the  diseased  joints  may  occur. 

As  complications  of  the  polyarticular  form  of  gonorrhoeal  rheuma- 
tism we  sometimes  see  sclerotic  iritis,  aquo-capsulitis,  bursitis,  and 
inflammation  of  tendinous  sheaths. 

There  are  certain  minor  forms  of  gonorrhceal  rheumatism  which  may 
or  may  not  present  conspicuous  objective  and  subjective  symptoms. 
These  are  inflammations  of  tendinous  sheaths,  of  bursae,  of  fasciae,  and 
of  the  extra-articular  structures.  The  tendinous  sheaths  may  be  affected 
alone  or  synchronously  with  the  joints.  Those  most  commonly  attacked, 
are,  as  before  stated,  the  extensors  of  the  hands  and  fingers,  the  dorsal 
flexors  of  the  toes  and  the  flexor  pollicis,  the  sheaths  of  the  biceps 
brachii,  and  the  tendo  Achillis.  The  visible  signs  of  this  affection  are 
redness  and  swelling  along  the  course  of  the  tendon.  This  elongated 
phlegmasia  is  more  or  less  painful,  and  causes  more  or  less  functional 
impairment  of  the  part  affected.  So  commonly  is  this  condition  due  to 
gonorrhoea,  and  so  strikingly  in  contrast  with  the  phlegmasic  non-pain- 
ful tendinitis  due  to  syphilis,  that  its  nature  will  be  readily  perceived. 
Tuberculous  inflammation  of  these  structures  may  be  attended  with  an 
acuteness  of  symptoms,  objective  and  subjective,  which  may  suggest 
gonorrhoea  as  their  origin.     This  point  should  always  be  borne  in  mind. 

Inflammation  of  bursae  due  to  gonorrhoea  shows  itself,  at  first,  as  a 
localized  red  and  rather  painful  swelling  of  the  part.  If  the  affection 
becomes  chronic,  the  redness  in  a  measure  disappears  and  the  part  be- 


GONORRHEAL  RHEUMATISM.  129 

comes  less  painful.  The  bursa?  of  the  tendo  Achillis,  of  the  os  calcis, 
wrist,  ankle,  patella,  and  tuberosity  of  the  ischium,  are  the  ones  most 
commonly  attacked.  This  affection  may  be  acute,  subacute,  and  chronic 
in  course. 

It  is  not  uncommon  to  find  concomitant  inflammation  of  tendinous 
sheaths  and  of  bursa?  in  the  course  of  polyarticular  acute  gonorrhoeal 
rheumatism. 

Inflammation  of  the  investing  structures  of  joints,  and  sometimes  of 
the  ends  of  large  and  expansive  tendons,  is  a  rather  infrequent  form  of 
gonorrhoeal  rheumatism,  and  is  termed  arthralgia.  This  condition  may 
exist  alone  or  in  conjunction  with  a  more  extended  development  of  the 
disease.  It  may  attack  the  outer  surface  of  one  or  more  large  joints  in 
whole  or  in  part.  There  may  or  may  not  be  redness  and  swelling,  but 
there  commonly  is  pain  of  an  acute,  aching,  persistent  character.  The 
area  of  pain  may  be  limited  to  an  inch  or  more  of  tissue,  and  it  may  be 
extensive.  There  is  usually  an  absence  of  general  symptoms.  This 
affection  may  last  several  weeks,  and  even  months,  but  it  generally 
yields  to  vigorous  counter-irritation. 

During  the  course  of  polyarticular  gonorrhoeal  rheumatism  the 
fibrous  sheaths  of  muscles  and  their  fascia?  are  sometimes  attacked. 
In  old  and  broken-down  subjects,  the  victims  of  very  chronic  and 
sometimes  never-ending  gonorrhoeal  rheumatism,  after  one,  several,  or 
many  of  their  joints  have  become  ankylosed,  the  disease  goes  on  and 
on,  attacking  the  fibrous  structures  of  muscles  and  bringing  about  their 
atrophy.  In  such  cases  also  we  may  find  persistent  arthritis  of  the  bones 
of  the  hands  and  feet,  which  results  in  permanent  disfigurement  and 
sometimes  great  deformity. 

In  some  cases  of  chronic  gonorrhoeal  rheumatism  sciatica,  mild  or 
severe,  may  occur. 

Diagnosis. — In  many  cases  the  existence  of  a  gonorrhoea  or  the  his- 
tory of  a  comparatively  recent  attack  will  suggest  the  nature  of  the  case 
under  observation.  In  the  main,  the  absence  of  sweating  and  the  com- 
paratively mild  systemic  reaction  (in  the  majority  of  cases)  will  suggest 
gonorrhoea  as  the  cause  of  the  rheumatism.  Then  the  predilection  of 
the  disease  to  attack  the  larger  joints,  particularly  of  the  knee,  ankle, 
wrist,  and  shoulder,  and  to  invade  only  one,  two,  or  three  joints,  is 
indicative  of  gonorrhoea  as  its  cause.  Hydrarthrosis  is  common  in 
gonorrhoeal  rheumatism,  and  is  infrequent  and  slight  in  the  ordinary 
form  of  the  disease.  The  absence  of  a  history  of  rheumatism  is  also 
significant  of  urethral  suppuration  as  a  cause.  The  coincident  involve- 
ment of  tendinous  sheaths,  fascia?,  and  bursa?,  with  perhaps  the  iris  and 
conjunctiva,  is  a  strong  point  against  the  case's  being  one  of  ordinary 
inflammatory  rheumatism. 


130  COMPLICATIONS  OF  GONORRHOEA. 

In  any  case  of  doubt  careful  examination  of  the  urine  should  be 
made,  and  if  threads  largely  composed  of  pus-cells  are  found,  the 
investigation  should  be  pushed  in  the  direction  of  gonorrheal  rheuma- 
tism. In  all  cases  of  obscure  localized  chronic  rheumatism  of  the  extra- 
articular structures,  fascia?,  tendinous  sheaths,  and  bursse,  a  suspicion  of 
urethral  suppuration  should  be  entertained  and  followed  up. 

Prognosis. — In  all  cases  of  involvement  of  the  larger  joints  by 
inflammatory  effusion,  the  patient  is  a  lucky  man  if  he  is  well  on  his 
feet  in  six  weeks  or  two  months.  When  several  joints  are  involved  the 
illness  will  be  still  further  protracted,  and  when  the  morbid  process  gives 
rise  to  serofibrinous  or  seropurulent  effusion  the  course  of  the  case  may 
be  protracted  for  several  or  many  months.  In  the  more  localized  forms 
of  gonorrheal  rheumatism,  without  much  systemic  reaction,  involving 
the  extra-articular  structures,  the  tendinous  sheaths,  fasciae,  and  bursa?, 
one,  two,  or  three,  and  even  more,  months  may  elapse  before  the  patient 
is  well  and  free  from  pain.  In  many  cases  the  cure  is  largely  dependent 
on  the  efficiency  and  vigor  of  the  treatment  adopted. 

Treatment. — The  golden  rule  in  the  treatment  of  all  cases  of  gonor- 
rheal rheumatism  is  to  cure  the  inflammation  in  the  urethra,  since  that 
is  the  source  and  origin  of  the  disease.  If  the  suppuration  is  subacute 
or  chronic,  it  must  be  treated  accordingly,  conforming  to  the  directions 
already  given.  Antiblennorrhagics  have  no  perceptible  effect  in  these 
cases.  In  general,  very  mild  nitrate-of-silver  irrigations,  thrown  into 
the  posterior  urethra,  are  suitable  for  subacute  cases  of  urethral  inflam- 
mation, and  more  concentrated  solutions  by  instillation  in  chronic  cases. 

When  joints  are  involved,  the  patient  must  at  once  be  placed  on  his 
back  and  the  affected  part  put  at  rest.  When  there  is  much  heat,  redness, 
and  swelling  of  the  joint,  cooling  applications,  such  as  ice-bags,  solution 
of  muriate  of  ammonia,  and  lead-and-opium  wash,  may  be  used.  In 
plethoric  subjects  temporary  ease  may  be  obtained  by  the  use  of  leeches. 
In  some  cases  a  flaxseed  poultice  in  which  laudanum  has  been  mixed 
gives  comfort.  In  every  case  the  patient  should  receive  (unless  con- 
traindicated)  enough  opium  or  morphine  to  make  him  comfortable. 
This  agent  rarely  fails  to  give  relief,  but  we  may  use  antipyrine  or 
phenacetine.  Salol,  salicylate  of  sodium,  boric  acid,  benzoic  acid,  uro- 
tropin,  muriate  of  ammonia,  nitrate  of  potash,  oil  of  wintergreen, 
colchicum,  iodide  of  potassium,  and  quinine  may  be  used  in  appropriate 
doses. 

With  the  decline  of  the  acuteness  of  the  joint-inflammation  much 
valuable  aid  can  be  given  to  the  case  by  very  active  blistering  of  the 
joint.  This  may  be  done  by  the  application  of  cantharidal  collodion, 
canthos,  or  a  fly-blister  spread  on  sheep-skin.  The  fully-developed 
blister  must  be  kept  "  open"  by  means  of  savine  or  tartar-emetic  oint- 


PERITONITIS  IN  THE  MALE.  131 

ment.  If  healing  of  the  skin  takes  place,  the  blister  must  be  applied 
again  in  the  same  vigorous  manner.  When  blisters  fail  to  cause  the 
hydrarthrosis  to  subside,  it  may  be  necessary  to  draw  off  the  contained 
fluid  and  to  irrigate  the  joint  with  sublimate  solution,  1  :  2000.  Keac- 
cumulation  of  the  fluid  demands  a  repetition  of  the  process. 

Over  limited  patches  and  areas  of  subacute  or  chronic  nature  strong 
tincture  of  iodine  or  pure  ichthyol  may  be  applied.  In  chronic  cases, 
particularly  those  in  which  the  joint-cavity  is  not  involved,  good  results 
follow  the  liberal  internal  use  of  iodide  of  potassium.  Indeed,  in 
several  cases  in  which  there  was  absolutely  no  history  of  syphilis  I 
have  seen  marked  benefit  follow  the  use  of  the  mixed  treatment  in 
combination  with  strong  mercurial  inunctions  and  of  mercurial  fumiga- 
tions. In  two  cases  of  gonorrhoeal  rheumatism  of  the  bursa?  in  front 
of  the  tendo  Achillis  I  produced  a  prompt  cure  by  the  injection  of 
fifteen  drops  of  a  5  per  cent,  watery  solution  of  carbolic  acid.  This 
treatment  may  be  used  in  all  limited  bursal  and  fascial  inflammations 
due  to  gonorrhoea. 

Paquelin's  cautery,  applied  to  limited  spots,  sometimes  tends  to  pro- 
mote resolution.  In  chronic  cases  massage  is  sometimes  surprisingly 
beneficial.  The  prolonged  systematic  use  of  dry  heat  in  high  degrees 
is  often  of  wonderful  benefit  in  causing  the  absorption  of  the  tissue- 
exudates  into  the  joint-structures.  In  all  chronic  cases,  where  prac- 
ticable, pressure  to  the  extent  of  tolerance  should  be  applied  to  the 
parts  by  means  of  elastic  bandages,  India-rubber  adhesive  plaster,  or 
plaster-of-Paris  splints.  When  suppuration  and  destruction  or  anky- 
losis of  joints  occur,  the  cases  are  to  be  treated  on  general  surgical 
principles  by  withdrawing  the  fluid  and  irrigating  the  joint.  Resection 
of  the  joint  may  be  necessary  when  the  cartilages  have  been  eroded  and 
the  bones  exposed. 

PERITONITIS   IN  THE   MALE. 

Inflammation  of  the  peritoneum  of  greater  or  less  severity  may 
result  from  the  extension  of  the  gonorrhoeal  process  from  some  part  of 
the  seminal  apparatus  to  that  portion  of  the  membrane  in  close  con- 
tiguity with  it. 

Gonorrhoeal  peritonitis  may  be  developed  by  acute  inflammation  of 
the  seminal  vesicles.  The  infectious  process  then  begins  in  the  recto- 
vesical cul-de-sac,  where  it  may  localize  itself,  or  it  may  spread  indef- 
initely from  that  morbid  centre. 

Gonorrhoeal  inflammation  of  the  vas  deferens  or  of  a  limited  seg- 
ment thereof  may  be  the  cause  of  peritonitis,  owing  to  the  fact  that 
these  anatomical  structures  are  for  a  considerable  distance  in  direct  con- 
tact with  each  other. 

Patients  attacked  by  gonorrhoeal  peritonitis  commonly  complain  of 


132  COMPLICATIONS  OF  GONORRHOEA. 

colic  at  first,  and  soon  direct  attention  to  the  tenderness  in  one  of  the 
iliac  fossa?  or  of  the  groin.  "With  the  extension  of  the  process  the  whole 
hypogastrium  may  become  swollen  and  tender,  and  from  that  the  whole 
abdominal  cavity  may  be  attacked.  The  symptoms  are  rapid  and  small 
pulse,  increased  respiration,  and  high  fever.  The  pain  is  intense,  par- 
ticularly on  pressure,  and  causes  the  patient  to  have  a  sallow,  drawn, 
and  anxious  facies.  There  may  be  obstinate  constipation,  and  excep- 
tionally diarrhoea.  In  many  cases  vomiting,  particularly  of  bile,  has 
been  observed.  There  is  usually  much  distention  of  the  abdomen.  In 
this  way  the  disease  may  run  on  and  end  in  recovery,  but  a  survey  of 
the  literature  shows  that  in  many  instances  death  has  ensued. 

In  many  cases  rectal  exploration  reveals  marked,  even  intense,  ten- 
derness or  pain  in  the  prostate  and  seminal  vesicles. 

Treatment. — The  patient  must  be  put  to  bed  as  soon  as  the  pro- 
dromal pains  are  felt.  If  he  is  of  vigorous  build,  leeches  may  be 
applied  over  the  painful  part.  Then  hot  poultices  must  be  kept  con- 
tinuously over  the  abdomen.  Opium  should  be  given  internally,  and 
all  symptoms  treated  according  to  their  indications. 

CARDIAC   AFFECTIONS. 

So  many  well-attested  cases  have  been  reported,  particularly  within 
the  past  ten  years,  in  which  cardiac  lesions  of  varying  degrees  of 
severity  have  developed  during  the  course  of  acute  and  chronic  gonor- 
rhoea that  there  is  now  no  longer  any  doubt  of  their  origin  in  this  viru- 
lent infectious  process.  Cardiac  complications  of  gonorrhoea,  however, 
are  very  rare,  since  in  all  less  than  fifty  cases  have  been  reported.  The 
male  sex  seems  to  be  the  one  most  liable  to  heart  complications  during 
gonorrhoea,  for  there  are  only  two  instances  on  record  in  which  they 
occurred  in  women.  In  the  majority  of  cases  cardiac  lesions  are  asso- 
ciated with  or  follow  gonorrheal  rheumatism  as  complications  of 
gonorrhoea. 

The  fibrous  and  serous  structures  of  the  heart  are  the  parts  primarily 
attacked,  the  endocardium  most  frequently,  and  the  pericardium  in  a 
smaller  percentage  of  cases. 

In  some  cases  the  symptoms  are  comparatively  mild,  and  recovery, 
though  generally  with  impaired  heart,  may  occur.  In  such  cases 
the  patients  complain  of  a  "  stitch "  in  the  left  chest  and  palpitation 
of  the  heart,  whose  action  is  accelerated  and  increased.  Sometimes  a 
slight  pericardial  crepitant  rale  may  be  heard.  In  the  mild  endocardial 
form  we  find  palpitations,  the  prolongation  of  the  first  sound,  with 
roughness  and  frequency  of  the  pulse.  There  may  be  prsecardial  dul- 
ness  and  distress,  and  bruit  de  souffle  at  the  base  with  the  first  sound. 
Soft  blowing  murmurs  are  sometimes  heard  at  the  apex.  It  is  thought 
that  the  aortic  valves  are  more  commonly  attacked  than  the  mitral. 


EXTERNAL    URETHRITIS.  133 

The  possibility  of  the  onset  of  cardiac  trouble  in  patients  suffering 
from  gonorrhoea  should  be  kept  in  mind  by  the  surgeon,  and  if  found, 
the  patient  should  at  once  be  put  to  bed  and  properly  cared  for. 

Reported  cases  show  that  a  very  grave,  even  deadly,  form  of  endo- 
carditis is  a  very  rare  complication  of  gonorrhoea.  In  these  cases, 
though  the  heart  affection  is  a  very  prominent  feature,  the  essential 
morbid  condition  is  really  pyemia. 

This  serious  disorder  is  probably  caused  by  the  pyogenic  microbes. 

The  prognosis  in  all  these  cases  is  grave. 

The  treatment  must  be  based  on  the  indications  presented. 

Pyaemia . 

Besides  the  cases  of  endocarditis  and  pericarditis  which  have  their 
origin  in  urethral  suppuration,  there  are  a  number  of  cases  of  pyaemia, 
in  some  of  which  there  were  heart-complications,  on  record,  in  which 
the  infection  was  derived  from  pus-foci  near  the  urethra. 

A  study  of  the  various  published  cases  of  pyaemia  following  gonor- 
rhoea shows  that  some  are  mild  in  character  and  end  in  recovery,  whilst 
others  are  of  a  malignant  type  and  end  in  death. 

AFFECTIONS   OF   THE   SPINAL   CORD. 

Within  a  few  years  cases  have  been  reported  in  which  there  was 
inherent  evidence  that  certain  spinal  affections  and  symptoms  had  their 
origin  in  urethral  gonorrhoea.  In  these  cases  dorsolumbar  pain,  girdle 
pain  around  the  lower  part  of  the  chest,  lightning  pains  in  the  lower 
limbs,  extreme  hyperesthesia,  motor  paresis,  exaggeration  of  the  reflexes, 
aud  epileptoid  trepidation  were  observed.  These  symptoms,  referable 
to  disease  of  the  cord  and  its  meninges,  recurred  severely  on  these  occa- 
sions coincidently  with  articular  lesions  and  the  recurrence  of  the  gon- 
orrhoeal  discharge.  In  a  reported  case  in  the  second  week  of  acute  gon- 
orrhoea the  patient  was  attacked  with  pain  in  the  region  of  the  crural 
nerves,  double  hydrarthrosis,  tarsal  and  tibio-tarsal  arthritis,  pains  in  the 
head,  lightning  pains,  exaggeration  of  knee-jerks,  epileptoid  trepidation, 
tremor  and  spasm  of  the  limb  when  the  foot  was  placed  on  the  ground, 
muscular  weakness,  and  dorsolumbar  pains,  followed  by  muscular 
atrophy. 

EXTERNAL   URETHRITIS. 

Under  the  title  external  urethritis  we  understand  several  varieties 
of  chronic  inflammation  which  have  their  origin  in  gonorrhoea,  arc 
seated  in  the  follicles  and  crypts  of  the  external  surfaces  of  the  penis, 
and  are  of  very  chronic  and  relapsing  character. 


134  COMPLICATIONS  OF  CONOBBHCEA. 

Inflammation  of  the  Preputial  Follicles. 

During  the  course  of  acute  gonorrhoea  or  following  such  an  attack 
we  sometimes  see  running  in  the  long  axis  of  the  penis,  between  the 
two  layers  of  the  prepuce,  a  little  line  of  inflammatory  tissue,  the  end 
of  which  is  usually  on  the  free  border  of  the  prepuce  or  just  within  its 
mucous  layer.  Careful  inspection  will  usually  show  that  this  little  line 
ends  in  a  minute  opening  of  the  size  of  a  pin's  head  or  of  a  pinhole, 
but  sometimes  it  may  not  be  visible  except  by  the  use  of  a  magnifying 
glass.  Pressure  on  this  little  blind  canal  usually  causes  a  small  droplet 
of  greenish  or  grayish  pus  to  exude  from  it.  This  sinus-like  lesion  may 
be  only  about  half  an  inch  long,  and  it  will  rarely  be  seen  longer  than 
an  inch. 

This  may  be  said  to  be  the  first  form  of  gonorrhoeal  preputial  follicu- 
litis. There  is,  however,  a  second  form,  in  all  probability  an  intensifi- 
cation of  the  first  form,  in  which  we  find  a  little  cherry-stone-sized 
nodule  or  abscess-cavity  situated  between  the  two  layers  of  the  prepuce 
which  has  a  well-marked  outlet  duct. 

Usually  there  is  but  one  follicular  abscess ;  very  rarely  two  are 
found.  During  the  exacerbations  of  these  chronic  sinuses  and  abscess- 
cavities  there  is  danger  of  auto-infection  of  the  urethra.  They  may  at 
these  times  also  be  the  source  of  infection  of  women. 

There  is  still  a  third  form  of  preputial  abscess.  During  an  attack  of 
gonorrhoea  a  small  red  spot  is  sometimes  seen  on  either  side  of  the  frse- 
num.  This  little  red  nodular  spot  soon  becomes  enlarged  and  elevated, 
of  the  size  of  a  pea  or  larger,  and  at  its  apex  a  minute  opening  is  soon 

Fig.  26. 


Follicular  abscess  of  the  prepuce  near  the  frssnum,  due  to  gonorrhoea. 

seen.  An  abscess  of  this  kind  may  burst  and  seemingly  heal  up,  or 
after  the  pus  has  been  discharged  and  the  inflammation  has  subsided  it 
may  be  again  infected  by  the  urethral  discharge,  and  again  be  the  seat 
of  abscess.  This  process  may  be  repeated  several  times.  In  some 
cases,  after  the  evacuation  of  the  pus,  usually  by  pressure  or  perhaps  by 


JUXTA-URETHRAL  SINUSES.  135 

a  slight  incision,  the  morbid  process  ceases  and  the  part  again  becomes 
healthy.  In  other  cases,  however,  the  abscess  is  very  persistent  and 
rebellious  to  treatment.  In  some  cases  the  nodule  grows  larger  and 
deeper,  and  perforation  of  the  urethra  may  occur.     (See  Fig.  26.) 

Persons  having  a  long,  tight,  or  a  straight  prepuce  or  one  with  a 
small  orifice  are  the  ones  who  suffer  most  from  the  chronicity  and  oft- 
time  recurrence  of  these  little  lesions.  Then,  again,  persons  who  for 
any  reason  suffer  from  balanitis  or  who  are  frequently  the  victims  of 
gonorrhoea  are  peculiarly  liable  to  these  abscesses.  It  is  not  uncommon 
for  one  of  these  abscesses  to  become  active,  and  for  its  pus  to  infect  the 
urethra  of  its  bearer,  without  any  infection  in  coitus. 

Suppuration  of  Follicles  of  the  Cutaneous  Investment  of  the  Penis. 

We  sometimes  see  on  the  under  surface  of  the  penis,  along  the  raphe 
even  as  far  back  as  the  scrotum,  small  suppurating  sinuses  and  follicles 
that  usually  have  a  well-marked  outlet  which  is  directed  forward 
toward  the  glans  penis.  Sometimes  these  lesions  are  tube-like,  and 
again  they  feel  like  minute  nodules.  They  may  be  seen  in  an  active 
state,  but  usually  they  are  shown  to  the  surgeon  when  there  is  no  com- 
plicating hyperemia  and  only  the  slight  discharge  on  pressure  from  the 
outlet  duct.  There  is,  as  a  rule,  one  such  lesion,  but  sometimes  there 
are  two,  rarely  more. 

The  structures  involved  in  these  cases  are  undoubtedly  sebaceous  fol- 
licles, and  they  are  usually  associated  with  hair-follicles.  Similar  fol- 
licular inflammation  may  be  found  along  the  dorsum  of  the  penis,  on 
the  middle  line,  as  far  as  the  symphysis  pubis.  One  or  more  follicles 
may  be  involved. 

Juxta-urethral  Sinuses. 

Not  infrequently  patients  present  themselves  to  the  surgeon  com- 
plaining of  a  slight  but  persistent  discharge,  which  they  say  comes 
from  one  or  both  lips  of  the  meatus.  Sometimes  the  affected  part  is 
distinctly  red,  and  again  it  may  appear  normal  in  tint.  It  sometimes 
happens  that  a  distinct  opening  can  be  seen,  and  it  is  usually  of  the  size 
of  a  pinhole.  Very  often  this  opening  is  hidden  in  the  uneven  papil- 
lary surface  of  the  meatus,  and  the  use  of  a  magnifying  glass  is  required 
to  make  it  clearly  visible.  Usually  pressure  on  the  glans,  particularly 
in  the  morning,  will  cause  a  droplet  of  pus  to  exude,  and  thus  the  outlet 
of  the  sinus  is  revealed.  Then,  again,  in  some  cases  a  thin,  minute 
crust  forms  from  escaping  pus,  and  removal  of  this  crust  reveals  the 
hidden  orifice.  These  sinuses  are  usually  seated  on  one  or  both  lips  of 
the  meatus  at  about  a  sixth  or  third  of  an  inch  from  its  inner  margin. 
In  most  cases  the  sinus  is  seated  in  the  middle  of  the  lip  of  the  meatus, 


136 


COMPLICATIONS  OF  GONORRHEA. 


Fig.  27. 


but  in  some  cases  it  opens  at  the  posterior,  and  quite  rarely  at  the  ante- 
rior, commissure.  There  may  be  one  or  two  such  sinuses  on  one  side, 
which  are  entirely  distinct  from  each  other  ;  then,  again,  cases  are  seen 
in  which  it  is  probable  that  the  two  sinuses  are  connected.  These 
morbid  canals  usually  run  backward  parallel  with  the  urethra,  but  in 
some  cases  they  pass  obliquely  backward  and  inward,  and  open  in  the 
fossa  navicularis,  forming  meato-navicular  fistulse.  It  is  not  at  all  un- 
common to  find  small  follicular  sinuses  which 
open  upon  the  urethra  as  far  back  as  an  inch 
from  the  meatus. 

These  little  lesions  may  exist  for  years, 
giving  issue  to  a  slight  discharge  and  causing 
no  uneasiness  of  mind  or  body.  In  some 
cases  we  get  a  clear  history  of  their  onset 
during  an  attack  of  gonorrhoea ;  in  others 
they  seem  to  originate  in  balanitis.  As  a 
rule,  they  remain  indolent  for  an  indefinite 
time,  but  are  liable  to  periods  of  exacerbation 
in  which  they  become  minute  but  conspicuous 
abscesses,  as  may  be  seen  by  inspection  of 
Fig.  27.  The  introduction  of  a  minute  probe 
shows  that  these  sinuses  vary  in  length  from 
an    inch,    and,    very    exceptionally,    a    little 


Juxta-urethral  sinus  during  a 
period  of  exacerbation. 


one-third    to    one-half 
longer. 

These  suppurating  canals  may  be  the  cause  of  auto-infection,  and  in 
some  cases  they  may  secrete  gonococci-containing  pus  by  which  the 
female  may  be  contaminated. 

Treatment. — In  the  treatment  of  the  preputial  follicular  lesions  the 
best  course  is  thorough  extirpation  as  soon  as  possible.  If  the  surround- 
ing tissues  are  in  a  state  of  hyperemia,  it  is  well  by  pressure  or  the  use 
of  the  knife  to  let  pus  out,  and  then  reduce  inflammation  by  the  use  of 
antiseptic  lotions.  Usually  there  is  such  a  redundance  of  tissue  in  the 
prepuce  that  thorough  removal  of  the  morbid  parts  is  possible  without 
any  damage  to  the  penis.  In  the  fossse  of  the  frsenum,  however,  these 
lesions  are  sometimes  imbedded  deep  in  the  tissues  and  are  adherent  to 
the  corpus  spongiosum.  In  such  cases  the  curette  may  often  be  freely 
used  to  advantage.  It  is  well  to  remember  that  in  some  cases  these 
lesions  of  the  frsenum  are  kept  in  an  active  state  by  balanitis,  and  that 
after  circumcision  the  source  of  irritation  ceases  and  the  part  soon  gets 
well. 

When  there  are  two  follicular  abscesses,  one  on  each  side  of  the 
framum,  it  will  be  necessary  to  dissect  them  out  carefully,  and  perhaps 
at  the  same  time  remove  that  fibrous  cord. 


PERI-UBETHRAL  ABSCESSES.  137 

Suppurative  follicles  of  the  integument  of  the  penis  should  be  incised 
and  thoroughly  curetted. 

The  treatment  of  juxta-urethral  sinuses  is  much  more  difficult.  It 
is  sometimes  expedient  to  enlarge  the  sinus  and  then  endeavor  to  obtain 
healing  from  the  bottom  by  means  of  stimulating  injections,  and,  if  pos- 
sible, a  minute  tampon.  The  ordinary  hypodermic  needle,  blunted  by 
the  removal  of  its  point,  is  very  useful  in  the  treatment  of  these  cases. 
After  careful  cleansing  and  antisepsis  a  drop  or  two  of  a  3  or  4  per  cent, 
nitrate-of-silver  solution  may  be  injected  every  second  day.  Good 
results  have  been  obtained  by  the  introduction  of  a  fine  probe  coated 
with  pure  nitrate  of  silver  which  had  previously  been  melted  by  heat. 

PERIURETHRAL  ABSCESSES. 

Abscesses  of  medium  and  large  size  are  not  infrequently  found  upon 
the  penis  near  the  frsenum  and  along  the  course  of  the  organ  as  far  back 
as  the  peno-scrotal  angle.  It  must  be  borne  in  mind  that  these  lesions 
are  of  greater  extent  and  severity  than  those  described  in  the  preceding 
section  as  follicular  inflammations. 

Peri-urethral  phlegmon  or  abscess  near  the  frsenum  is  usually  a  con- 
comitant of  acute  gonorrhoea  or  it  may  occur  in  the  chronic  stage  of 
that  process.  In  some  cases,  in  primary  attacks,  it  appears  during  the 
height  of  the  urethral  suppuration,  in  others  toward  the  period  of 
decline,  and  only  exceptionally  in  the  later  stage.  It  usually  begins  as 
a  red  and  tender  spot  on  one  side  of  the  frsenum.  This  inflammatory 
condition  may  increase  rapidly,  and  again  its  growth  may  be  rather 
slow.  In  either  event  it  is  soon  seen  that  an  abscess  is  in  process  of 
formation.  These  abscesses  are  in  general  round  and  globular,  but 
their  shape  is  determined  by  the  topographical  arrangement  of  the 
frsenum  and  the  tissues  forming  its  fossse  and  the  prepuce.  Sometimes 
the  tumor  is  round,  and  again  it  may  be  oval  shape.  In  Fig.  28  an 
oval  abscess  of  the  left  frsenal  fossse  is  well  shown. 

Perhaps  in  the  majority  of  cases  these  abscesses  occur  unilaterally 
and  are  tolerably  well  circumscribed.  When  of  goodly  size  the  inflam- 
matory oedema  which  accompanies  the  suppurative  process  may  involve 
the  tissues  on  the  unaffected  side  of  the  penis.  This  is  also  well  shown 
in  Fig.  28. 

Then,  again,  in  somewhat  exceptional  cases  an  abscess  forms  in  one 
frsenal  fossa,  increases  rapidly  and  extensively,  and  passing  under  the 
frsenum,  involves  the  other  fossa  in  the  suppurating  process.  This  is 
well  shown  in  Fig.  29,  in  which  all  the  connective  tissue  at  the  under 
part  of  the  glans  is  involved  in  abscess-formation.  The  frsenum  then 
divides  the  abscess  into  two  lobes. 

It  also  happens,  somewhat  rarely,  that  the  tissues  of  each  fossa  of 


138 


COMPLICATIONS  OF  GONORRHOEA. 


the  frsenum  become  affected  separately,  in  which  event  there  are  two 
distinct  abscesses. 

In  any  of  these  cases  the  patient  experiences  more  or  less  pain  at 
the  part  involved.  In  somewhat  rare  instances  there  is  constitutional 
disturbance,  as  shown  by  chills,  fever,  and  loss  of  appetite.  The  press- 
ure of  the  tumor  upon  the  urethra  may  affect  the  force  and  shape  of  the 
stream  of  urine  or  occasion  dysuria  amounting  even  to  retention. 

AYhen  incised  and  properly  treated  these  abscesses  heal  up  promptly. 
In  some  cases,  however,  particularly  when  proper  care  has  not  been 


Fig.  28. 


Fig.  29. 


Abscess  near  the  frsenum,  producing 
moderate  paraphimosis. 


Abscess  near  the  franum  involving  both 
fossee. 


taken,  the  abscess-cavity  contracts  down  into  a  small  inflammatory 
nodule  which  remains  indefinitely.  This  inflammatory  nodule  some- 
times redevelops  into  an  abscess  with  each  recurrent  attack  of  gonor- 
rhoea or  balanitis. 


Abscesses  of  the  Follicles  of  the  Urethra. 

These  lesions  begin  as  inflammatory  foci  either  in  Littre's  follicles 
or  the  crypts  of  Morgagni.  During  the  acute  and  declining  stages  of 
gonorrhoea  we  frequently  feel  with  the  finger-tips  one  or  more  or  many 
little  millet-seed  and  even  larger  nodules  in  the  corpus  spongiosum. 
These  little  circumscribed  swellings  are  undoubtedly  swollen  follicles. 
In  most  cases,  for  the  reason  that  we  find  gonococci  in  the  pus  coinci- 
dently  with  the  follicular  inflammation,  it  is  fair  to  assume  that  the 
morbid  process  is  caused  by  those  microbes.  Follicular  inflammation 
occurring  after  the  cure  of  gonorrhoea — a  not  very  frec^uent  conolition — 


ABSCESSES  OF  THE  FOLLICLES  OF  THE   URETHRA.  139 

may  be  clue  to  the  action  of  other  microbes,  perhaps  the  streptococci  or 
staphylococci.  It  may  be  stated  quite  positively  that  in  most  of  the 
cases  of  gonorrhceic  follicular  inflammation  resolution  takes  place  syn- 
chronously with  the  cessation  of  the  major  process. 

Follicular  abscesses  of  the  urethra  may  develop  in  the  fossa  navicu- 
lars. These  suppurations  are  here,  as  a  rule,  not  of  large  extent,  the 
abscess  being  usually  of  the  size  of  a  pea.  The  smallness  of  the  follicu- 
lar abscess  in  this  region  is  probably  due  to  the  density  of  the  tissues 
and  to  the  absence  of  much  connective  tissue.  Usually,  when  the 
process  is  complete,  pus  is  discharged  into  the  urethra,  and  a  short  sinus 

Fig.  30. 


Abscess  of  the  follicles  of  the  urethra. 

leading  to  a  small  cavity  is  left.  This  may  heal  of  itself  or  may  require 
local  treatment.  In  somewhat  rare  cases  the  abscess  of  the  fossa  navicu- 
laris  extends  deeply  into  the  tissues  and  opens  on  the  outside  in  either 
fossa  of  the  frsenum.  (See  Fig.  30.)  In  this  event  there  is  much  danger 
of  a  permanent  urethral  fistula.  Careful  treatment,  aided  by  nature,  or 
nature  alone  may  close  the  wound,  but  there  is  always  a  strong  proba- 
bility that  the  fistula  will  be  permanent.  A  plastic  operation  is  some- 
times of  benefit  in  these  cases. 

Farther  down  the  urethral  canal  follicular  abscesses  are  not  at  all 
uncommon.  They  begin  as  small,  round,  painful  swellings,  which  in 
their  early  stage  are  easily  circumscribed  by  the  fingers.  They  usually 
go  on  more  or  less  promptly  to  suppuration,  which  is  attended  by  much 
inflammatory  oedema  of  the  corpus  spongiosum  and  the  connective  tissue 
external  to  it.     (See  Fig.  31.) 

The  tendency  to  relapse  observed  in  these  follicular  urethral  lesions 
is  shown  in  Fig.  32,  in  which  a  large  swelling  (the  tenth  of  a  series)  of 
the  middle  of  the  under  part  of  the  penis  is  portrayed.  As  is  common 
in  these  relapsing  phlegmons,  the  inflammatory  process  was  not  very 
acute,  though  there  was  considerable  suppuration. 

In  most  of  these  cases  of  follicular  suppuration  of  the  urethra  the 


140 


COMPLICATIONS  OF  GONORRHOEA. 


swelling  is  out  of  all  proportion  to  the  amount  of  suppuration.     There 
is  usually  very  much  inflammatory  oedema,  but  the  suppurating,  cavity 


Fig.  31. 


Tery 


Fig.  32. 


Large  abscess  of  the  follicles  of  the  urethra  during  gonorrhoea. 

usually   contains    from  half  a  drachm  to  a  drachm  of  pus.     In 
large  phlegmons  two  or  three  drachms  may  be  found. 

There  are  two  dangers  to  be  looked 
for  in  these  cases  of  follicular  abscess 
of  the  urethra.  The  one  is  urethral 
fistula ;  the  other  is  the  formation, 
after  the  abscess  bursts  into  the  m*e- 
thra,  of  an  inflammatory  nodule.  This 
inflammatory  nodule  is  always  a  men- 
ace to  the  patient.  It  resolves  itself 
into  a  little  lump,  in  most  cases  easily 
felt,  usually  on  the  lower  wall  of  the 
urethra.  In  its  relaxed  condition  occa- 
sionally it  may  be  so  small  and  insig- 
nificant that  it  can  be  scarcely  felt,  but 
during  erection  its  presence  is  readily 
made  out.  It  may  thus  remain  for 
months  or  years ;  but,  as  a  rule,  with 
every  recurrence  of  gonorrhoea  the  sup- 
Abscess  of  the  follicles  of  the  urethra   purative   process   lights    up   again   and 

(tenth  attack).  i  -       n  -\         mi  • 

a  new  abscess  is  tormed.  Ihis  may 
occur  again  and  again  for  many  years.  In  some  cases  the  abscess- 
formation   becomes   more   intense,  and   pus   is   discharged   externally 


ABSCESSES   OF  THE  FOLLICLES  OF  THE   URETHRA.  141 

through  the  inflamed  and  eroded  skin.  In  these  obstinate  eases  a 
urethral  fistula  remains,  which  is  usually  permanent  and  requires  for  its 
relief  a  plastic  operation.  In  favorable  cases  the  inflammatory  nodule 
undergoes  contraction,  and  finally  ends  in  a  small  cicatrix. 

In  many  of  these  cases  of  follicular  phlegmon  of  the  urethra  the 
morbid  process  is  limited  to  the  urethral  wall  proper,  and  it  is  in  these 
cases,  even  when  suppuration  occurs,  that  resolution  and  cure  commonly 
result.  In  the  more  severe  cases  the  follicular  abscess  increases  beyond 
the  urethral  tissue  proper  into  the  connective  tissue  between  it  and  the 
corpus  spongiosum.  It  may  continue  still  farther  and  involve  more  or 
less  or  all  of  the  corpus  spongiosum.  As  the  suppurative  process  thus 
progresses  outwardly,  in  most  cases  a  wise  provision  of  nature  occurs. 
With  the  establishment  of  the  suppurative  process  in  the  deep  part  of 
the  urethral  wall,  or  in  the  contiguous  connective  tissue,  or  in  this  and 
in  the  corpus  spongiosum,  an  adhesive  inflammation  obliterates  the  little 
follicular  cavity  in  the  urethral  wall,  the  damage  is  repaired,  and  the 
then  outlying  abscess  is  shut  off  from  all  communication  with  the  ure- 
thra. This  abscess  then  has  as  its  base  the  healed  urethral  wall,  while 
its  sides  and  roof  are  formed  by  the  infected  tissues  of  the  corpus  spon- 
giosum, the  subcutaneous  connective  tissue,  and  the  skin  itself. 

It  may  happen,  unfortunately,  that  this  walling  off  of  the  abscess- 
cavity  by  adhesive  inflammation  does  not  occur,  and  then  there  is  much 
reason  for  apprehension  that  a  permanent  fistula  will  follow  the  resolu- 
tion of  the  inflammatory  process.  Even  should  urine  escape  in  these 
cases,  all  hope  need  not  be  given  up,  since  sometimes,  most  unexpectedly, 
healing  takes  place,  the  urethra  is  not  left  perforated,  and  we  find  at  the 
seat  of  the  trouble  a  little  line  or  nodule  of  firm  structure  which  we 
know  is  the  cicatrix.  When,  however,  the  parts  are  well  healed  and  a 
sinus  remains,  it  may  usually  be  looked  upon  as  permanent,  unless 
relieved  by  a  plastic  operation. 

There  is  still  another  condition  which  is  sometimes  observed.  The 
abscess  opens  into  the  urethra,  and  there  is  left  a  cavity  and  an  internal 
blind  fistula  or  sinus  leading  to  it.  In  favorable  cases  the  parts  retract 
until  the  lesion  ends  in  a  little  cicatricial  mass ;  but  sometimes  this 
happy  result  is  not  attained,  and  the  cavity  and  its  duct  remain.  Then 
urine  leaks  into  the  wound,  and  slowly  or  quickly  an  abscess  again 
forms.  This  may  occur  again  and  again,  and  may  finally  end  in  a 
fistula  leading  from  the  urethra  to  the  outside.  Then,  again,  even 
when  abscesses  have  repeated  themselves  under  these  conditions  many 
times,  thorough  healing  may  finally  occur. 

Abscess  of  Cowper's  Glands. 

Cowper's  glands  which  are  seated  between  the  two  layers  of  the  tri- 
angular ligament  may  be  the  seat  of  abscess  due  to  gonorrhoea.     They 


142 


COMPLICATIONS   OF  GONORRHOEA. 


usually  occur  at  about  the  same  period  as  epididymitis,  during  the  third 
or  fourth  week  of  gonorrhoea  or  later.  Usually  but  one  gland  is 
affected,  quite  exceptionally  both  are  involved,  and  in  this  they  are 
similar  to  abscess  of  Bartholin's  gland.  The  peculiarity  of  these 
abscesses  is  that  they  are  seated  on  either  side  of  the  raphe  or  median 
line.  In  their  early  stages  these  phlegmons  are  felt  as  little  cherry- 
sized  round  or  oval  swellings  just  at  the  triangular  ligament.  With  the 
development  of  the  abscess-process  the  patient  experiences  pain,  uneasi- 
ness, and  tension  in  the  perineum  near  the  bulb,  which  is  aggravated  in 

Fig.  33. 


Abscess  of  Cowper's  gland. 

the  sitting  position,  in  walking,  and  by  pressure  and  friction  of  the 
clothes.  With  the  increase  in  the  phlegmonous  process  the  pain 
becomes  severe,  and  in  many  cases  there  are  chills,  fever,  and  malaise. 
Owing  to  the  swelling,  the  urethra  is  not  unfrequently  pressed  upon, 
and  dysuria,  and  even  retention,  may  result.  As  the  abscess  increases 
in  size  it  pushes  outward  and  forms  a  tense  red  swelling  in  the  peri- 
neum, or  it  pushes  forward  and  juts  out  at  the  penoscrotal  angle. 
While  at  first  the  swelling  is  seated  on  one  side  of  the  raphe,  when  it 


ABSCESS  OF  COWPERS  GLANDS.  143 

becomes  very  extensive  it  encroaches  on  the  opposite  side.  When  the 
abscess  is  very  large,  as  it  sometimes  is,  the  whole  perineum  becomes 
red  and  swollen.     (Fig.  33.) 

In  most  cases  abscess  of  Cowper's  glands  is  an  acute  process,  but  in 
some  it  takes  place  quite  slowly.  Usually  the  swelling  extends  from 
the  bulb  into  the  tissue  beyond,  and  the  abscess  either  opens  or  is 
opened  in  the  perineum  or  in  the  scrotum.  The  further  course  of  these 
abscesses  is  similar  to  that  of  those  just  described.  The  abscess  may 
be  walled  off,  and  then  when  opened  may  be  healed  from  the  bottom,  or 
the  sinus  leading  into  the  urethra  may  remain  patulous,  in  which  case 
there  is  left  a  perineal  or  scrotal  fistula.  In  the  majority  of  cases  the 
urethral  lesion,  which  consists  of  the  duct  of  the  gland  in  a  state  of 
inflammation,  heals,  and  no  bad  results  are  finally  left.  In  rather 
exceptional  cases  a  fistula  results. 

It  sometimes  happens,  particularly  when  the  abscess  is  not  very 
large,  that  it  opens  through  the  duct  into  the  bulb,  and  the  pus  then 
escapes  through  the  urethra.  In  this  event  it  may  happen  that  subse- 
quent contraction  may  obliterate  the  abscess-cavity  and  its  duct.  Then, 
again,  it  is  rather  more  common  to  find  that  considerable  contraction 
occurs — that  the  morbid  process  becomes  circumscribed  to  a  nutmeg- 
sized  or  even  larger  mass,  and  this  may  remain  indolent.  This  condi- 
tion is  always  one  of  ill  omen,  since  it  so  frequently  forms  a  focus  for 
the  re-formation  of  abscesses.  Thus  one  phlegmon  after  another  may 
form  and  burst  into  the  urethra  over  a  period  of  many  years.  Some- 
times this  recurrence  of  the  phlegmonous  process  is  lighted  up  by  fresh 
attacks  of  gonorrhoea  or  by  exacerbations  of  a  chronic  gonorrhoea! 
process.  Then,  again,  in  many  instances  the  new  suppuration  is  seem- 
ingly due  to  the  leakage  of  urine  into  the  inflamed  nodule. 

Quite  rarely  still  another  course  may  be  taken  by  the  Cowper's-gland 
abscess.  In  the  original  inflammation  there  may  be  considerable 
oedematous  hyperplasia  of  the  gland  and  tissues  immediately  surround- 
ing it,  and  some  pus  may  be  formed,  but  the  whole  abscess-swelling  is 
of  a  subacute  character,  and  less  in  size  than  a  walnut.  After  the 
escape  of  the  pus  a  nodule  is  left,  which  for  a  time  may  or  may  not 
remain  quiescent.  Then  it  gradually  grows,  and  a  firm  somewhat 
painful  swelling,  without  much  redness,  appears  in  the  perineum.  This 
swelling,  which  is  for  a  long  time  on  one  side  of  the  raphe,  increases 
very  slowly,  occupying  two  and  even  many  months  in  its  course.  It 
presents  a  hard,  firm  structure,  and  fluctuation  cannot  be  detected  for 
a  long  time.  Finally,  the  necessity  for  opening  the  abscess  becomes 
evident,  pus  escapes,  and  usually  a  fistula  leading  to  the  bulbous  urethra 
is  left.  But  even  in  these  cold  chronic  abscesses  the  walling  off  of  the 
suppurative  process  may  occur  and  no  fistula  may  be  left. 


144  COMPLICATIONS  OF  GONOBRHCEA. 

Treatment. — Until  the  suppurative  process  is  ripe  it  is  well  to 
apply  lead-and-opium  wash,  or  muriate  of  ammonia,  or  carbolic  solu- 
tions. When  fluctuation  is  felt,  a  liberal  but  careful  incision  should  be 
made  over  the  prominence  of  the  swelling  and  the  abscess-cavity  should 
be  irrigated  with  bichloride  solution  1  :  2000.  Then  the  wound  should 
be  dusted  with  iodoform  or  aristol  and  packed  with  sterilized  gauze. 
In  the  somewhat  rare  event  of  a  fistula  being  left  it  may  be  necessary 
to  perform  a  plastic  operation. 

GONORRHEAL   OPHTHALMIA. 

Gonorrhoeal  ophthalmia  is  happily  a  rare  accident  rather  than  a  com- 
plication of  gonorrhoea.  It  is  a  violent  and  often  destructive  inflamma- 
tion, and  more  intense  than  purulent  conjunctivitis.  It  is  developed  in 
the  eyes  of  young  infants  during  delivery,  from  gonorrhoeal  pus  in  its 
mother's  vagina.  The  usual  mode  of  infection  in  adults  is  the 
transference  of  the  pus  from  the  genitals  to  the  eyes  by  means  of  the 
fingers.  In  some  cases  the  pus  of  the  infected  eye  is  carried  to  the 
other  by  the  fingers  during  sleep  or  by  accident  during  the  day.  Towels 
and  linen  are  also  said  to  be  the  vehicles  of  infection. 

The  virulent  form  of  ophthalmia  has  been  shown  to  be  caused  by 
pus  containing  gonococci.  A  less  virulent  form  is  said  to  be  due  to  pus 
not  containing  gonococci,  but  other  pyogenic  microbes.  In  the  majority 
of  cases  of  the  milder  affection  the  symptom-complex  is  much  less  severe 
than  in  gonorrhoeal  ophthalmia,  but  in  some  cases  the  severity  is  seem- 
ingly just  as  great.  All  forms  of  chronic  urethral  and  vaginal  pus  should 
be  regarded  as  dangerous. 

This  form  of  ophthalmia  is  said  to  be  more  common  in  men  than  in 
women,  for  the  reason,  probably,  that  gonorrhoea  is  so  much  more  fre- 
quent in  the  former  than  in  the  latter.  It  may  occur  in  the  acute  stage 
of  gonorrhoea,  but  it  is  generally  seen  during  the  declining  stage.  It 
may  be  confined  to  one  eye  or  may  later  on  attack  the  other  one. 

Symptoms. — The  first  symptoms,  which  usually  begin  in  a  few  hours 
or  as  late  as  thirty  hours  after  infection,  are  hyperemia  of  the  con- 
junctiva, an  itching  sensation  at  the  margin  of  the  lids,  as  if  caused  by 
a  foreign  body,  soon  followed  by  increased  lachrymation,  a  gumming  of 
the  ciliee  together,  and  collection  of  little  masses  of  mucus  at  the  inner 
canthus.  The  watery  secretion  soon  becomes  mucoid  and  very  shortly 
purulent.  A  conjunctivitis,  mild  at  first  and  limited  to  the  lids,  but 
later  on  of  a  severe  type  involving  the  ocular  mucous  membrane,  which 
is  elevated  above  the  sclerotic  coat,  is  then  seen.  All  of  the  conjunctival 
surface  is  then  of  a  very  deep-red  color,  much  swollen,  producing  ever- 
sion  of  the  lids,  and  roughened  from  distention  of  the  papilla?.  The 
intense  chemosis  of  the  conjunctiva  bulbi  is  well  shown  in  Fig.  34,  in 


GONORRHCEAL   OPHTHALMIA. 


145 


Fig.  34. 


■■■■^mL 


) 


which  the  red,  swollen,  and  infiltrated  membrane  surrounds  the  cornea 
like  a  pad.  At  this  time  the  secretion  is  purulent  and  profuse,  and 
redness  and  oedema  of  the  integument 
of  the  lids  are  present. 

The  amount  of  pain  occasioned  by 
this  disease  varies  in  different  cases. 
During  the  development  and  acme  of 
the  inflammation  it  is  generally  severe. 
It  is  described  by  the  patient  as  a  sensa- 
tion of  burning  heat  and  tension  in  the 
eyeball,  radiating  to  the  brow  and  the 
temple.  The  system  at  large  sym- 
pathizes with  the  local  disease.  For 
a  time  there  may  be  general  febrile 
excitement,  but  symptoms  of  depression 
may  soon  appear ;  the  pulse  becomes 
rapid  and  irritable,  the  skin  cold  and 
clammy,  and  the  patient  anxious  and 
nervous.  Notwithstanding  the  severity 
of  the  symptoms,  resolution  is  still  pos- 
sible. Under  proper  care  and  treatment 
the  inflammatory  action  may  abate  and 
the  tissues  recover  their  normal  condi- 
tion, leaving  the  eye  as  sound  as  before 

the  attack.     So  fortunate  a  result  is  more  to  be  hoped  for  than  con- 
fidently anticipated. 

Prognosis. — The  prognosis  is  always  grave,  especially  so  when  both 
eyes  are  attacked.  If  treatment  is  instituted  at  an  early  period,  the 
chances  of  the  patient  are  best.  If  ulceration  of  the  cornea  has  taken 
place,  they  are  bad.  Sometimes  the  whole  cornea  is  extruded  and  the 
contents  of  the  eye  escape.  An  eye  has  been  known  to  be  thus  destroyed 
within  twenty-four  hours,  and  even  in  a  single  night. 

According  to  the  extent  and  situation  of  the  ulceration  the  eye  is 
more  or  less  permanently  injured.  When  superficial  and  marginal,  the 
resulting  opacity  of  the  cornea  may  not  interfere  with  the  sight,  which 
may  be  impaired  if  the  leucoma  is  central.  Perforation  of  the  anterior 
chamber  and  prolapse  of  the  iris,  when  partial,  may  also  be  remedied 
by  art ;  but  when  the  whole  or  the  larger  part  of  the  cornea  has  sloughed 
away,  and  the  prolapsed  iris  has  become  covered  with  a  dense  layer  of 
fibrin,  forming  an  extensive  staphyloma,  the  case  is  hopeless.  In  gen- 
eral, when  less  virulent  micro-organisms  are  found,  the  prognosis  is  not 
grave.     The  earlier  a  case  of  gonorrhoeal  ophthalmia  is  seen  and  proper 

treatment  is  commenced,  the  better  is  the  prognosis.     In   infants  the 
10 


\ 


146  COMPLICATIONS  OF  GONORRHOEA. 

prognosis  largely  depends  on  the  care  which  the  case  receives.  In  early 
adult  life  there  is  such  resistance  of  the  tissues  that  with  care  the  inflam- 
mation may  be  controlled.  Toward  middle  age  and  in  elderly  subjects 
the  tissue-resistance  is  not  as  great,  and  the  prognosis  then  is  more 
serious. 

Diagnosis. — So  much  do  severe  cases  of  purulent  ophthalmia  re- 
semble those  of  the  gonorrhceal  form  that  a  sharp  diagnosis  is  often 
impossible,  owing  to  the  meagreness  of  the  history.  Any  intense  form 
of  ophthalmia,  whatever  may  be  its  origin,  must  be  looked  upon  in  as 
serious  a  li^ht  as  that  due  to  £onorrhcea.  ^n  a^  cases  the  pus  should  be 
examined  microscopically  at  once,  and  if  the  gonococcus  is  found  it  is 
absolutely  certain  that  the  case  is  of  gonorrhceal  origin,  and  therefore  a 
very  grave  one. 

Treatment. — The  first  indication  in  treatment  is  to  procure  two 
nurses — one  for  the  day,  the  other  for  the  night — who  shall  be  in  con- 
stant attendance.  They  should,  at  the  outset,  be  thoroughly  impressed 
with  the  gravity  of  the  case,  instructed  as  to  their  duties,  and  showTn  the 
technic  of  opening  the  eye  and  removing  the  pus.  They  must  be 
warned  of  the  intense  infectiousness  of  the  secretions,  must  be  directed 
to  keep  their  hands  and  nails  in  a  thoroughly  aseptic  condition,  and  they 
should  provide  themselves  with  a  pair  of  large  protective  concave  spec- 
tacles. In  case  one  eye  only  is  affected,  the  other  may  be  covered  by 
Buller's  shield.  Or  the  sound  eye  may  be  covered  with  cotton  wool 
strapped  down  with  adhesive  plaster,  over  which  a  solution  of  gutta- 
percha is  painted.     In  young  subjects  it  is  well  to  secure  the  hands. 

If  seen  before  inflammation  has  fully  developed,  four  to  six  leeches 
may  be  applied  at  the  external  canthus  or  to  the  mucous  membrane  of 
the  corresponding  nostril,  or  if  not  at  hand  cups  may  be  used  on  the 
temples.  The  character  of  the  inflammation  being  manifest,  a  careful, 
continuous,  and  energetic  treatment  must  be  followed.  Constant  appli- 
cation of  cold  is  then  absolutely  required.  This  is  accomplished  by 
means  of  small  pieces  of  linen  of  a  single  thickness,  wdiich,  when  thor- 
oughly chilled  upon  a  piece  of  ice,  should  be  laid  over  the  eye,  and 
replaced  by  another  every  two  or  three  minutes  in  very  intense  cases. 
These  pieces  of  linen  should  be  burned  immediately  after  use.  The 
further  treatment  of  the  case  should  be  as  follows,  after  the  manner 
proposed  by  my  friend,  Dr.  J.  A.  Andrews  :  When  the  inflammation  is 
fully  established,  the  indications  are  to  w7ash  away  the  pus  in  the  most 
perfect  manner  as  soon  as  possible,  and  to  render  the  conjunctival  sur- 
face aseptic.  For  this  purpose  a  saturated  solution  of  boracic  acid  is 
necessary.  A  bichloride  solution,  1  :  10,000  or  20,000,  may  also  be 
used.  This  may  be  used  by  means  of  Andrews'  irrigator  No.  2,  or  by 
means  of  a  piece  of  fine  rubber  tubing  attached  to  a  fountain  syringe, 


SEEOVASCULAR   CONJUNCTIVITIS.  147 

and  allowed  to  flow  with  the  utmost  gentleness.  These  irrigations  must 
be  repeated  as  often  as  necessary.  Then,  from  the  beginning  of  the 
disease,  a  2  per  cent,  solution  of  nitrate  of  silver  should  be  dropped, 
rather  than  brushed,  into  the  eye  by  the  surgeon,  since  it  is  then  dis- 
tributed by  the  movement  of  the  eyelids.  When  there  is  considerable 
discharge  and  the  conjunctiva  is  much  swollen,  the  silver  solution  should 
be  used  once  daily,  but  it  should  not  be  repeated  so  long  as  the  action 
already  produced  by  one  application  is  present.  Great  care  should  be 
taken  that  the  silver  is  not  applied  to  the  cornea.  Should  the  latter 
become  involved  we  may  resort  to  atropine.  Instillations  of  a  four- 
grains-to-the-ounce-of-water  solution  of  atropine  may  be  used  also  at 
intervals  during  the  severity  of  the  attack.  As  improvement  takes 
place,  the  use  of  the  solution  of  nitrate  of  silver  should  be  more  infre- 
quent until  it  is  finally  dropped. 

If  chemosis  has  taken  place,  the  ocular  conjunctiva  and  subjacent 
connective  tissue  should  be  divided  by  means  of  blunt  scissors,  and  in 
case  the  eversion  of  the  lids  is  not  complete,  the  outer  commissure 
should  be  freely  divided,  together  with  the  canthal  ligament,  for  the 
inflamed  surfaces  must  be  in  such  a  condition  that  they  can  be  thor- 
oughly treated.  Excessive  oedema  of  the  lids  interfering  with  the 
opening  of  the  eye  may  be  relieved  by  minute  punctures  of  the  skin. 
After  the  subsidence  of  the  acute  symptoms  the  nitrate-of-silver  solu- 
tion, which  toward  the  end  has  been  used  much  less  frequently  than  at 
first,  may  be  replaced  by  a  solution  of  sulphate  of  zinc. 

The  granular  condition  of  the  conjunctiva  should  be  treated  by  the 
application  of  a  piece  of  sulphate  of  copper  to  the  surface  every  second 
or  third  day. 

Patients'  suffering  from  gonorrheal  ophthalmia  should  occupy  a 
large,  well-ventilated  room,  which  should  be  moderately,  not  wholly, 
darkened,  and  they  should  be  placed  exclusively  in  the  care  of  the 
surgeon  and  nurses.  At  the  onset  of  the  disease  a  brisk  aperient,  even 
a  cathartic,  may  be  given,  which  should  be  repeated  as  necessary,  care 
being  taken  that  the  patient's  strength  is  not  impaired  by  it.  A  mild 
diet,  gruels  and  light  broths,  may  be  taken.  Should  evidences  of  mal- 
nutrition and  debility  appear,  with  weak  and  irritable  pulse,  more 
nutritious  food  of  the  most  digestible  character  must  be  given,  together 
with  tonics,  and  perhaps  ale,  porter,  milk-punch,  etc.  It  must  be  re- 
membered that  the  vitality  of  the  corneal  tissue  is  very  low,  and  that 
its  destruction  may  be  hastened  by  an  impoverished  state  of  the  system. 

Serovascular  Conjunctivitis. 
This  is  a  rare  form  of  purulent  conjunctivitis  of  which  little  has 
been  written.     This  form  of  ophthalmia  is  really  a  complication  of 


148  COMPLICATIONS  OF  GONORRHOEA. 

gonorrhoea,  and  not  one  of  its  accidents.  Though  the  pathogenesis  of 
this  affection  has  not  been  studied,  much  less  made  out,  I  think,  reason- 
ing by  analogy,  that  it  will  later  on  be  settled  that  it  is  an  infectious 
process  due  to  septic  absorption,  like  gonorrhoeal  rheumatism,  etc.  It 
certainly  is  not  due  to  pus-contamination. 

This  affection  begins  in  a  painless  and  insidious  manner,  but  its  ob- 
jective symptoms  are  well  marked.  The  patient  at  first  feels  a  slight 
heat  in  the  eye  and  a  sensation  as  if  some  particle  had  lodged  on  it. 
Then  the  conjunctiva  bulbi  becomes  rather  swollen  and  hypersemic. 
This  is  followed  by  hypersemia  of  the  conjunctiva  of  the  lids.  The 
secretion  is  at  first  serous  and  moderately  copious,  but  in  a  few  days  it 
becomes  slightly  purulent.  In  the  acme  of  the  inflammation  we  find 
the  whole  conjunctiva  rather  swollen,  with  perhaps  some  oedema  of  the 
eyelids.  The  mucous  membrane  is  of  a  quite  deep-red  color  and  of 
velvety  appearance.  The  oedema  is  not  usually  very  extensive.  The 
affection  runs  an  indolent  course,  and  usually  does  not  cause  much  pain 
or  annoyance.  One  or  both  eyes  may  be  affected.  After  cure  a  relapse 
is  not  uncommon.  I  have  seen  several  cases  in  which  patients  were 
thus  affected  with  each  attack  of  gonorrhoea. 

The  prognosis  is  almost  invariably  good. 

Treatment. — The  eye  should  be  irrigated  with  saturated  boric- 
acid  solution,  and  a  few  drops  of  a  2  per  cent,  solution  of  nitrate  of 
silver  may  be  dropped  in  the  eye  once  or  twice  a  day.  Ice-cloths  may 
be  necessary. 


CHAPTER   IX. 

GONORRHCEA  IN  THE   FEMALE. 

In  many  cases  of  gonorrhoea  in  women  the  history  of  the  period  of 
invasion  is  very  obscure.  In  some  the  sudden  onset  of  the  affection  in 
a  previously  healthy  woman,  in  a  woman  recently  married,  or  in  a  woman 
having  had  but  a  single  intercourse  may  give  positive  clues  as  to  the 
early  stage  of  the  disease.  In  very  many  cases,  however,  the  patient 
gives  the  history  of  having  suffered  for  a  long  period  with  chronic 
leucorrhcea,  and  of  having  experienced  an  exacerbation,  and  then 
examination  reveals  acute  inflammation  of  the  external  and  perhaps 
internal  genitalia. 

GONORRHCEA  OF  THE  URETHRA. 

Gonorrhoea  of  the  urethral  canal  is  the  most  common  form  observed 
in  women.  Formerly  gonorrhoea  of  the  vagina  ranked  first  in  impor- 
tance and  frequency,  but  recent  observations  and  studies  have  conclu- 
sively proved  that  the  virulent  suppuration  caused  by  the  gonococcus  is 
most  frequently  found  in  the  urethra.  The  disease  may  be  limited  to 
the  urethra,  and  it  may  exist  at  the  same  time  with  gonorrhoea  of  the  os 
uteri.  In  some  cases  there  is  a  coexistent  vulvitis,  and,  particularly  in 
young  subjects,  the  vagina  may  also  be  involved,  either  as  a  whole  or  in 
part. 

Urethral  gonorrhoea  in  the  female  resembles  in  some  particulars  the 
same  form  in  the  male.  It  has  a  period  of  incubation,  as  shown  by 
experimental  inoculations  both  with  virulent  pus  and  the  cultivated 
gonococcus,  of  about  two  days,  which  may  be  protracted  to  five  days. 

As  a  rule,  the  invasion  of  the  urethra  in  the  female  is  much  the 
same  as  in  the  male.  There  is  the  slight  tickling  and  burning  sensa- 
tion, and  the  same  seromucous  secretion  in  which  little  whitish  particles 
may  be  seen  suspended,  which  under  the  microscope  are  shown  to  be 
epithelial  cells  and  gonococci.  Then,  after  a  prodromal  period  of  a  few 
hours  or  a  day  or  two,  the  acute  stage  develops,  with  more  or  less  severe 
burning  in  the  urethra,  rendered  worse  on  urination,  which  soon  becomes 
quite  frequent.  Examination  of  the  parts  shows  the  urethral  orifice  to 
be  very  red  and  swollen,  with  perhaps  a  pouting  prominence  of  its  lips. 
A  greenish-yellow  discharge  escapes  in  considerable  quantity,  and  may 

149 


150  GOXORRHCEA   IN  THE  FEMALE. 

cause  redness  and  swelling  of  the  parts  around  and  beneath.  The  pres- 
ence of  the  finger-tip  inserted  in  the  vagina  shows  that  the  urethra  is 
swollen  and  tender,  and  pressure  from  behind  forward  causes  pus  to 
exude  from  the  meatus.  The  urethra  being  such  a  short,  nearly  straight 
tube,  ending  directly  in  the  bladder,  that  viscus  may  be  early  involved 
in  the  inflammation.  Examination  of  the  urine  by  the  two-glass  test 
will  always  show  how  deeply  the  morbid  process  has  travelled.  If  the 
first  specimen  is  cloudy  and  the  second  clear,  it  is  certain  that  the  blad- 
der is  not  involved.  If  the  second  specimen  is  turbid,  then  it  is  certain 
that  the  bladder  has  been  infected. 

In  some  cases  of  acute  urethral  gonorrhoea  in  women  there  may  be 
mild  febrile  movement  and  malaise.  As  a  rule  their  local  sufferings  are 
quite  acute  at  this  time,  and  they  usually  become  worse  when  the  blad- 
der is  involved.  Then  in  bad  cases  there  is  constant  tenesmus,  and  as  a 
result  the  frequent  urinations  cause  great  agony ;  not  infrequently  the 
patient's  sufferings  are  increased  by  the  urine  scalding  the  inflamed 
contiguous  parts. 

In  the  majority  of  cases  of  the  acute  stage  of  urethral  gonorrhoea  in 
the  female,  amelioration  of  the  symptoms  begins  in  about  a  week  or  ten 
days,  and  even  sooner.  The  burning  and  scalding  become  less  and  less 
severe,  the  tenesmus  is  less  imperative,  and  the  urinations  become  less 
frequent  and  painful.  The  redness  and  swelling  of  the  meatus  subside 
slowly,  and  the  pus  becomes  whitish  and  mucoid.  In  this  way  matters 
grow  progressively  better  until  the  chronic  stage  may  be  reached.  Then 
we  commonly  see  a  normal  or  only  slightly  red  meatus,  from  which,  by 
intravaginal  pressure  on  the  urethra,  a  drop  or  two  of  viscid  mucopus 
or  a  thinner  milky-looking  fluid  may  escape.  In  this  condition  the 
woman  may  suffer  no  discomfort  whatever,  or  she  may  have  a  very 
slight  smarting  or  a  sensation  of  heat  on  urination. 

Microscopical  examination  of  the  pus  in  the  florid  stage  shows  pus- 
cells  with  many  gonococci.  As  the  secretion  becomes  more  mucoid, 
epithelial  cells  show  prominently  in  the  field,  with  a  diminished  number 
of  gonococci.  In  the  chronic  stage  there  are  usually  found  some  pus- 
cells,  epithelial  cells,  a  few  gonococci,  and  the  usual  indifferent  microbes. 
Later  on  no  gonococci  can  be  seen.  In  this  chronic  stage,  when  the 
bladder  has  remained  intact,  the  first  ounce  of  water  passed  into  the 
first  vessel  will  contain  some  clumps  and  filaments  of  pus  and  epithe- 
lium, while  the  urine  in  the  second  vessel  will  be  clear.  When  there  is 
a  complicating  cystitis  the  urine  in  the  second  glass  will  be  nearly  as 
turbid  as  that  in  the  first  glass. 

Many  women  have  this  chronic  form  of  urethral  inflammation  for  a 
long  time,  even  for  years.  Its  secretion  in  the  early  months  is  infectious. 
Later  on  the  process  is  simply  a  post-gonorrhceal  urethritis,  and  the  pus 


GONORRHOEA    OF  THE   OS    UTERI  AND    UTERUS.  151 

then  is  harmless.  As  a  rule,  the  urethral  secretion  becomes  innocuous 
in  about  six  months  or  a  year  after  the  date  of  infection,  as  I  have 
myself  many  times  seen.  This  is  shown  by  the  impunity  with  which 
men  cohabit  with  women  who  have  this  emasculated  secretion.  In  its 
active  stages,  however,  the  pus  of  gonorrheal  urethritis  of  women  is 
equally  as  virulent  as  that  of  men  similarly  afflicted. 

In  the  declining  and  chronic  stage  of  urethral  gonorrhoea,  in  the 
absence  of  symptoms  and  of  swelling  and  redness  of  the  urethral  orifice, 
the  way  to  diagnosticate  the  trouble  is  by  intravaginal  pressure  on  the 
urethra  from  behind  forward,  or  by  the  examination  of  the  urine,  which 
is  passed  several  hours  after  a  previous  urination  which  has  cleansed  the 
canal.  Women  very  frequently  urinate  just  before  presenting  themselves 
to  the  surgeon,  who  then  fails  to  obtain  a  secretion  in  the  meatus  by 
pressure  on  the  urethra.  The  woman  under  suspicion  should  not  be 
allowed  to  urinate  or  use  injections  on  the  same  day  that  she  applies 
for  examination,  and  the  surgeon  should  decline  to  give  an  opinion  if 
she  does. 

In  chronic  urethritis  in  women  it  is  not  common  to  see  the  exacer- 
bations of  the  trouble  which  are  so  frequent  in  men.  In  the  majority 
of  cases  the  intra-urethral  and  peri-urethral  glands  only  beome  infected 
in  the  declining  stage  of  the  urethritis.  Therefore  these  forms  of  inflam- 
mation will  be  considered  farther  on  separately.  Since  there  are  no 
mucous  follicles  along  the  course  of  the  female  urethra  beyond  the  first 
half  inch,  as  there  are  in  man,  we  do  not,  as  a  rule,  find  those  deep- 
seated  follicular  abscesses  which  are  almost  peculiar  to  men. 

GONORRH(EA  OF  THE  OS  UTERI  AND  UTERUS. 

The  chief  importance  of  gonorrhoea  of  the  os  uteri  resides  in  the  fact 
that  from  this  focus  the  uterus  itself  and  the  parts  above  in  direct 
anatomical  connection  may  be  invaded  early  or  late  by  the  infection. 

Gonorrhoea  of  the  os  uteri  is  very  probably  contracted  in  intercourse 
with  men  who  are  in  the  declining  stage  of  acute  gonorrhoea.  During 
the  acute  stage  men,  by  reason  of  the  pain,  swelling,  and  discharge, 
refrain  from  coitus,  but  as  the  trouble  subsides  they  often  weary  of 
continence,  have  intercourse,  and  infect  their  consorts. 

The  anatomical  position  of  the  os  is  such  that  in  coitus  it  generally 
comes  in  contact  with  the  apex  of  the  glans  penis,  and  there  becomes 
bathed  with  the  ejaculation  which  carries  with  it  pus  from  the  still 
inflamed  urethra,  unless  the  latter  tube  has  been  thoroughly  flushed  by 
recent  urination.  When  the  vagina  is  short,  and  when  the  uterus  rests 
low  in  the  pelvis,  the  chances  of  infection  are  great.  Consequently, 
when  the  uterus  is  placed  high  up  the  os  may  escape  infection.     The 


152  GONORRHCEA   IN  THE  FEMALE. 

length  of  the  penis  and  the  duration  of  the  sexual  act  also  have  bearing 
upon  the  infection  of  the  os. 

Gonorrhoea  of  the  os  uteri  may  be  the  sole  evidence  of  a  given  infec- 
tion, which  may  begin  in  this  part,  and  there  remain  until  cured.  It 
also  coexists  in  many  cases  with  a  urethritis  of  similar  origin.  Then, 
again,  the  pus  escaping  from  the  uterine  orifice  not  infrequently  infects 
the  vagina,  usually  in  a  localized  manner,  and  rarely  in  the  totality  of 
the  tube.  In  only  acute  and  very  severe  cases  is  the  os  infected  by 
extension  of  the  disease  from  the  urethra  up  the  vagina. 

In  the  majority  of  cases  gonorrhoea  of  the  os  uteri  begins  in  an 
insidious  manner  unattended  with  marked  symptoms.  The  external 
and  internal  surfaces  of  the  os  become  red  and  swollen,  and  they  give 
forth  a  mucopurulent  secretion.  Some  women  will  complain  of  exces- 
sive discharge  ;  while  others,  who  have  long  had  vaginal  secretions,  may 
pay  no  attention  to  an  increase,  even  if  it  is  decidedly  copious.  Thus  it 
is  that  this  affection  is  seldom  seen  in  its  very  early  days. 

When  a  woman  suffering  from  gonorrhoea  of  the  os  uteri  is  examined 
by  means  of  the  speculum,  nothing  absolutely  characteristic  or  diag- 
nostic can  be  seen.  The  os  is  swollen,  and  is  more  or  less  red,  even  to 
a  purplish  tint.  At  first  the  mucous  membrane  is  swollen  and  has  a 
velvety  appearance.  From  the  os  a  purulent  or  mucopurulent  discharge 
escapes  in  large  drops,  and  around  the  os  is  a  narrow  collarette  of  red- 
ness and  erosion.  Then,  when  the  os  is  much  enlarged,  it  may  be 
eroded  in  totality  or  in  part.  Sometimes  there  are  many  small  erosions, 
and  again  there  may  be  several  quite  large  ones.  Though  these  erosions 
are  sometimes  called  ulcerations,  they  are  simply  local  losses  of  epi- 
thelium, such  as  we  see  in  tolerably  well-marked  cases  of  erosive 
balanitis.  When  the  inflammatory  process  runs  higher  and  there  is 
much  exudative  inflammation,  the  outer  surface  of  the  os  presents  a 
mammillated  appearance,  probably  from  the  swelling  and  prominence 
of  the  muciparous  glands.  This  condition  may  become  so  wrell  marked 
that  the  appearances  of  the  os  resemble  those  of  a  very  rough  orange. 
Then,  again,  the  surface  of  the  os,  in  very  severe  cases,  may  become 
quite  deeply  eroded  and  present,  as  pointed  out  by  Rollet,  the  ap- 
pearance of  a  deep-red  cherry  whose  skin  has  been  peeled  off. 
With  a  still  greater  increase  in  the  morbid  process  granulations,  per- 
haps a  few  and  perhaps  in  abundance,  may  develop  on  the  external 
surface  of  the  uterine  neck  and  on  the  contiguous  mucous  membrane, 
particularly  that  part  below  the  posterior  lip  of  the  os  uteri.  These 
granulations  may  be  of  millet-seed  size,  and  they  may  resemble  the 
papillse  of  raspberries  and  strawberries.  In  the  course  of  time  these 
granulations  may  go  on  and  develop  into  true  warty  growths,  which 
may  later  on  become  epitheliomatous.     Over  the  morbid  surface  we  fre- 


GONORRHOEA    OF  THE  OS   UTERI  AND    UTERUS.  153 

quently  find  a  film  or  membrane  of  thick  greenish  pus,  and  from  the  os 
a  purulent  fluid  escapes.  In  many  of  these  cases,  when  fully  devel- 
oped, the  patients  complain  of  dysmenorrhea  and  too  frequent  and  too 
copious  menstruation.  It  is  these  menstrual  symptoms  which  often 
cause  the  patients  to  seek  medical  advice,  and  then  a  correct  diagnosis 
may  be  made. 

In  a  goodly  number  of  cases  the  tissue-changes  on  the  external 
surface  of  the  os  are  very  slight,  consisting  of  a  mild  increase  of  red- 
ness, with  or  without  moderate  erosion. 

Even  when  there  is  a  marked  condition  of  erosion  the  external  epi- 
thelium may  be  restored,  while  at  the  same  time  the  morbid  process 
persists  in  the  lumen  of  the  os.  The  main  cause  of  the  chronicity  of 
gonorrhoea  of  the  uterine  neck  is  the  localization  of  the  process  in  the 
numerous  and  deeply  seated  glands  of  Naboth,  with  their  plentiful 
blood-supply.  As  the  affection  grows  old,  even  if  little  or  indifferent 
treatment  is  followed,  the  discharge  in  many  cases  becomes  less  puru- 
lent and  more  mucoid,  so  that  in  its  chronic  stage  this  form  of  gonor- 
rhoea may  only  give  as  an  objective  symptom  the  well-known  glassy- 
white  mucous  plug  which  hangs  from  the  os  so  constantly.  This  plug 
resembles  those  of  the  ordinary  simple  inflammations  of  these  parts ; 
and,  while  it  frequently  contains  gonococci  in  its  meshes,  there  is  no 
visible  sign  present  to  denote  its  virulent  character.  In  many  cases 
the  only  means  of  determining  the  presence  of  gonococci  in  the  os  is  to 
curette  it  gently,  and  then  examine  the  detritus  microscopically. 

Throughout  the  whole  course  of  gonorrhoea  of  the  os  this  segment 
may  not  be  the  seat  of  pain,  and  its  examination  by  bimanual  manipu- 
lation may  give  rise  to  little  if  any  unpleasant  sensation.  Pain,  how- 
ever, is  quite  exceptionally  felt,  either  spontaneously  or  as  a  result  of 
physical  examination. 

Now,  it  must  be  confessed  that,  with  all  the  objective  phenomena  just 
presented,  there  are  no  appearances  which  may  not  be  found  in  simple 
affections  of  the  uterine  neck.  How,  then,  can  we  establish  a  diagnosis 
of  gonorrhoea?  In  some  cases  the  facts  of  an  infecting  coitus  may  be 
established.  In  others  (when  the  trouble  is  clearly  recognized)  the 
onset  of  an  endocervicitis  in  a  healthy  young  woman,  who  has  not  been 
tampered  with  to  produce  abortion,  who  has  not  undergone  any  form  of 
minor  gynecological  treatment,  and  who  has  not  had  any  disturbance  of 
menstruation,  may  cause  the  suspicion  of  gonorrhoea!  infection  in  coitus. 
In  many  cases,  early  in  their  course  it  is  very  easy  to  find  the  gonococ- 
cus  in  the  pus,  which  must  be  taken  by  means  of  a  platinum  loop  from 
within  the  cervical  cavity,  the  orifice  of  which  has  been  rendered  clean 
and  sterile.  Then,  again,  we  frequently  meet  with  cases  in  which  a 
profuse,  very  yellow,  purulent  discharge  escapes  from  the  os,  in  which 


154  GONOBRHCEA   IN  THE  FEMALE. 

discharge  the  most  scrutinizing  examination  fails  to  reveal  the  gono- 
coccus  or  perhaps  any  hostile  microbe. 

The  conclusion  warranted  by  all  these  facts  is,  that  while  it  is  cer- 
tain that  gonorrheal  infection  of  the  os  uteri  is  of  very  frequent  occur- 
rence, it  is  often  overlooked.  It  may  present  no  objective  or  subjective 
symptoms  which  distinguish  it  from  simple  processes,  while  the  facts  of 
the  case  may  occasionally  point  to  gonorrheal  infection  in  coitus.  In 
these  cases,  when  recent,  the  microscope  may  reveal  the  gonococcus, 
and  thus  dispel  all  doubt.  Then,  again,  as  the  morbid  process  grows 
old,  even  the  microscopic  evidence  may  grow  less  and  less  striking  and 
certain ;  so  that  in  many  cases,  in  the  absence  of  the  gonococcus,  it 
having  played  its  part  and  disappeared,  there  is  no  diagnostic  evidence 
of  any  kind  to  prove  that  the  case  started  out  in  gonorrheal  infection. 

Gonorrhea  of  the  os  uteri  very  often  presents  in  a  clear  manner  the 
fallibility  of  the  doctrine  of  the  gonococcus.  In  many  cases  gonorrhea 
in  men  can  be  traced  to  gonococci-containing  pus  or  mucopus  from  the 
os  uteri  of  an  infected  woman.  In  many  other  cases,  where  this  is  the 
only  segment  of  the  genital  tract  that  is  the  seat  of  inflammation,  the 
most  elaborately  careful  examination  of  the  secretion,  even  when  pro- 
cured by  scraping,  fails  utterly  to  show  any  gonococci,  while  other 
microbes  may  be  seen.  Yet  the  men  who  have  cohabited  with  these 
women  may  have  florid  gonorrhea,  with  gonococci-containing  pus. 

In  the  larger  number  of  cases  the  gonorrheal  process  ceases  at  the  os 
internum.  Whether  this  normal  constriction  of  the  parts  has,  as  claimed 
by  some,  any  tendency  to  act  as  a  barrier  to  the  infection,  we  cannot 
positively  say. 

Gonorrheal  Endometritis. — By  the  extension  of  the  gonorrheal 
process  beyond  the  os  internum  the  mucous  membrane  of  the  body  of 
the  uterus  is  attacked  by  its  characteristic  inflammation.  When  the 
uterus  is  attacked,  there  may  be  fever,  a  sensation  of  heat,  and  bearing- 
down  pains  in  the  pelvis  which  radiate  to  the  back.  There  may  also  be 
nausea  and  vomiting.  In  this  acute  form  the  uterus  is  tender  on  press- 
ure, and,  when  practicable,  bimanual  palpation  shows  that  the  organ  is 
much  swollen  in  all  directions.  There  may  be  suppression  of  the  menses 
or  menorrhagia.  The  uterine  secretion  is  abundant,  purulent,  or  muco- 
purulent in  character,  and  perhaps  mixed  with  blood,  and  in  it  the  gono- 
coccus can  readily  be  demonstrated.  The  vagina  is  hot,  and  the  cervix 
is  red,  swollen,  and  eroded.  Where  the  history  of  the  case  points  to 
gonorrhea,  the  diagnosis  may  be  made  with  the  aid  of  the  microscope. 
There  are  no  pathognomonic  symptoms  whatever,  either  objective  or 
subjective,  by  which  a  positive  diagnosis  of  gonorrhea  can  be  arrived 
at.  In  some  cases  acute  recent  gonorrhea  of  the  husband,  followed  by 
symptoms  of  acute  infection  in  the  wife,  clearly  points  to  the  virulent 


GONORRHCEA   OF  THE   VAGINA.  155 

origin  of  the  process,  which  may  be  confirmed  by  the  aid  of  the  micro- 
scope. 

Acute  gonorrheal  metritis  passes  into  the  chronic  form,  in  which  the 
diagnosis  becomes  more  and  more  difficult,  since  in  the  absence  of  a 
clear  history  the  gonococcus  is  the  only  criterion,  and  this  microbe 
grows  less  numerous,  and  even  disappears,  in  proportion  as  the  process 
grows  old.  In  the  chronic  stage  the  case  belongs  to  the  domain  of  the 
gynaecologist  (and  it  is  to  be  hoped  that  the  one  consulted  is  a  cool  and 
conservative  man),  whose  advice  should  be  sought  unless  the  attendant 
is  especially  skilled  in  women's  diseases. 

GONORRHCEA   OF   THE   VAGINA. 

Gonorrhoea  of  the  vagina  may  be  found  in  young  girls,  whose 
vaginal  mucous  membrane  is  yet  succulent,  and  who  have  not  been 
accustomed  to  sexual  intercourse,  which  tends  to  cornification  of  its 
epithelium.  In  some  rather  older  girls  or  women,  in  whom  the  mucous 
membrane  is  still  soft  and  normally  quite  hyperaemic,  gonorrhceal  infec- 
tion may  occur.  Then,  again,  in  women  whose  vaginae  possess  the 
normal  resistance  the  continued  contact  of  the  gonorrheal  pus  from 
the  cervix  or  uterus  may  produce  a  localized  vaginal  gonorrhoea. 

Gonorrhoea  of  the  vagina  may  be  local  or  general,  acute  or  chronic. 
Very  commonly,  little  can  be  learned  of  its  onset,  since  it  is  liable  to 
occur  in  women  the  subjects  of  uterine  or  vaginal  leucorrhoea.  Then, 
again,  women,  as  a  rule,  are  less  communicative  and  truthful  regarding 
their  amours  than  men  are ;  consequently,  the  date  and  source  of  con- 
tagion are  always  with  difficulty,  and  many  times  are  never,  ascertained. 
Carelessness  of  the  person,  and  the  indifference  which  comes  to  many 
women  about  vaginal  discharges,  very  frequently  tend  to  prevent  the 
surgeon  obtaining  a  satisfactory  history  of  the  case. 

When  seen  early  a  vagina  affected  with  gonorrhoea  presents  a  dry 
red  surface,  which  is  the  seat  of  a  sensation  of  heat.  Very  soon  a 
mucoid  fluid  is  seen,  which  soon  becomes  mucopurulent.  In  its  fully 
developed  stage  the  secretion  of  vaginal  gonorrhoea  is  a  pus  of  consider- 
able consistence  and  of  a  milky  color,  due  to  the  admixture  of  large 
quantities  of  epithelial  scales. 

When  gonorrhoea  of  the  vagina  is  due  to  extension  of  the  inflam- 
mation from  the  external  genitalia,  it  is  attended  with  all  the  symptoms 
incident  to  the  latter,  together  with  a  sense  of  burning  heat,  which  is 
referred  by  patients  as  deep  down  in  the  pelvis.  The  vaginal  orifice  and 
carunculae  myrtiformes  are  reddened,  swollen,  and  eroded,  and  con- 
stantly bathed  with  pus.  In  the  cases  under  consideration,  if  treatment 
is  adopted  promptly,  only  a  small  portion  of  the  lower  vagina  may  be 
involved.    Untreated,  however,  the  tendency  of  the  disease  is  to  become 


156  GONOBBHCEA   IN  THE  FEMALE. 

firmly  fixed  and  chronic,  and  to  localize  itself  in  the  upper  parts  of  the 
vagina,  particularly  in  its  posterior  fornix  or  Douglas's  cul-de-sac.  In 
some  cases  it  is  found  to  attack  the  anterior  fornix,  and  in  others  both 
recesses,  anterior  and  posterior  to  the  uterus. 

Acute  gonorrhoea  originating  in  the  vagina  proper  is  sometimes  seen 
to  involve  its  lower  third  ;  but  may  occur  at  any  part,  particularly  on  its 
posterior  aspect.  When  severe  and  extensive,  it  gives  rise  to  great  suf- 
fering in  the  form  of  a  continuous  burning  pain  in  the  pelvis,  which  is 
much  aggravated  by  motion,  walking,  and  even  by  sitting  down.  So 
great  is  the  swelling  of  the  vaginal  orifice,  and  so  extreme  the  tenderness, 
that  the  introduction  of  the  finger  or  of  an  instrument  is  impossible, 
and  patients  beg  that  the  nozzle  of  the  syringe  shall  not  be  inserted, 
and  if  at  all  a  very  small  one.  When  the  acute  stage  is  fully  developed, 
the  sufferings  of  the  patient  are  often  further  increased  by  extension 
of  the  disease  to  the  urethra  and  vulva.  Under  these  circumstances  her 
condition  is  often  pitiable,  as  may  well  be  imagined  from  the  extent  of 
surface  involved.  The  duration  of  the  acute  stage  is  very  variable,  and 
depends  largely  upon  the  efficacy  of  treatment  and  upon  the  regularity 
with  which  it  is  followed.  In  general,  a  week  or  ten  days  elapse  before 
topical  treatment  can  be  instituted  in  the  vaginal  canal.  Then  much 
can  be  done,  provided  the  woman  can  be  kept  in  bed  and  properly 
attended  to  ;  but  women  thus  afflicted  are,  as  a  rule,  careless  patients, 
and,  though  the  gravity  of  their  case  be  pictured  to  them  in  the  clearest 
manner,  they  in  very  many  instances  backslide.  Then,  again,  the  recur- 
rence of  the  menstrual  epoch,  with  its  engorgement  of  the  genito-urinary 
tract  and  sometimes  its  irritating  secretion,  is  often  a  very  serious  set- 
back. In  private  and  dispensary  practice  we  constantly  see  these 
patients  reach  a  subacute  condition,  and  then  disappear;  and  even 
in  the  hospital  they  often  consider  themselves  well  and  demand  their 
discharge  long  before  the  surgeon  deems  it  prudent. 

Subacute  gonorrhceal  vaginitis  is  seen  in  two  principal  forms — the 
one  limited  to  the  lower  segment  of  the  tube,  and  usually  rather  more 
severe  on  its  posterior  wall ;  the  other  and  more  frequent  one  in  the 
cul-de-sac  behind  the  uterus.  Besides  these,  the  affection  may  be  seen 
to  be  seated  anterior  to  the  uterus  and  in  the  middle  third  of  the  vagina. 
When  occurring  in  the  lower  two-thirds  of  the  vagina,  the  membrane 
is  found  to  be  red,  swollen,  in  places  eroded,  thrown  into  large  folds, 
and  bathed  with  pus.  When  the  inflammation  is  seated  low  down,  the 
introitus  vaginae  and  the  tissues  immediately  around  it  are  more  or  less 
inflamed. 

Gonorrhoea  of  the  posterior  vagina  or  Douglas's  cul-de-sac  is  not  of 
infrequent  occurrence.  In  this  position  it  is  very  liable  to  escape  detec- 
tion unless  carefully  looked  for.     To  this  end,  the  best  opportunity  for 


GONORRHOEA    OF  THE   VAGINA.  157 

a  thorough  examination  is  offered  by  the  genupectoral  position  ;  though 
very  often,  from  feelings  of  delicacy,  we  cannot  insist  upon  it.  The 
next  best  position  is  that  of  Sims,  with  his  speculum  ;  but  it  is  in- 
ferior, in  my  experience,  to  the  genupectoral  position.  In  the  latter,  a 
Sims  speculum  may  be  used,  or  one  made  of  thin  nickel-plated  wire, 
such  as  is  found  in  the  shops.  Thus  exposed,  the  mucous  membrane  is 
seen  to  be  deep  red,  oedernatous,  and  more  or  less  excoriated  and  covered 
with  copious  creamy  greenish  pus  mixed  with  glairy  mucus.  In  most 
cases  there  is  coexistent  inflammation  of  the  os  uteri  in  the  form  of  a 
deep-red,  easily  bleeding,  inflammatory  areola,  and  from  it  a  mucopuru- 
lent plug  may  hang.  In  some  cases  the  gonorrhoeal  inflammation  ex- 
tends only  as  far  as  the  os  internum,  but  in  others  the  uterine  cavity  is 
affected. 

Besides  the  cases  of  gonorrhoea  of  the  vagina  which,  from  the  sudden 
onset  of  the  affection  and  from  its  violent  nature,  are  regarded  as  due 
to  direct  contagion,  we  frequently  see  vaginitis — or,  as  it  has  been  of  late 
years  termed,  elytritis — develop  in  persons  subject  to  cervical  and  cor- 
poreal endometritis  and  chronic  subacute  inflammation  of  the  vagina. 
The  history  of  the  beginning  of  the  trouble  is  usually  very  vague,  though 
in  some  cases  excessive  and  unnatural  coitus  and  uncleanliness  seem  to 
be  the  exciting  causes.  Morbid  constitutional  conditions  may  tend  to 
intensify  this  inflammation. 

Vaginitis  of  more  or  less  severity  occurs  in  the  young,  middle-aged, 
and  old  in  less  severe  form  than  that  already  described.  This  variety 
is  termed  by  authors  simple  vaginitis  ;  and  it  has  been  stated  that  it  can 
be  differentiated  from  the  severe  forms  by  the  fact  that  in  the  latter  the 
secretion  is  acid  in  reaction,  while  in  the  former  it  is  alkaline.  The 
clinical  description  of  the  severe  form  has  been  given ;  and  it  is  only 
necessary  to  say  that  in  every  feature  the  mild  affection  is  much  less 
severe.  In  these  mild  cases,  however,  exacerbations  may  be  observed, 
and  the  affection  may  become  as  severe  as  those  of  gonorrhoeal  origin. 

As  a  result  of  gonorrhoeal  vaginitis,  the  mucous  membrane  is  some- 
times found  to  be  thickened  and  granular.  These  granulations  are  due 
to  exuberant  epithelial  proliferation  and  new  vessel-formation,  and  may 
be  scattered  over  the  whole  tube,  or  may  be  localized  particularly  in  its 
posterior  wall. 

Some  observers,  notably  gynecologists,  claim  that  simple  vegetations 
or  warts  are  symptomatic  of  gonorrhoeal  inflammation.  This  statement 
is  incorrect  and  misleading.  Vegetations  result  from  any  chronic 
irritative  process  by  which  the  parts  are  kept  hot  and  moist.  They  are 
frequently  seen  in  women  who  never  had  connection  and  were  un- 
cleanly. They  may  occur  during  the  course  of  any  catarrhal  process  of 
the  vagina  or  vulva,  and  may  develop  in  the  course  of  gonorrhoea. 


158  GONORRHOEA   IN  THE  FEMALE. 

Gonorrhoea  of  the  vagina,  therefore,  may  be  caused  by  the  extension 
upward  of  the  infection  from  the  vulva,  and  it  may  also  result  from 
infection  by  virulent  pus  from  the  cervix  uteri.  True  gonorrhoea, 
limited  to  the  vagina  proper,  may  be  seen  rather  exceptionally  in  quite 
young  women. 

GONORRHCEA   OF   THE   VULVA. 

Gonorrhoea  may  originate  primarily  in  the  vulva,  or  it  may  be  caused 
by  contact  with  gonorrhceal  pus  from  the  vagina  and  parts  above.  As 
a  primary  affection  it  is  not  very  common,  and  is  usually  seen  in 
girls  of  from  fifteen  to  twenty  years  of  age  as  a  result  of  rape  or  coitus 
which  is  difficult  of  accomplishment,  owing  to  the  then  compact  and 
unstretched  condition  of  the  parts.  It  is  this  natural  impediment  to 
intromission  which  causes  the  external  infection  by  the  gonorrhceal  pus 
from  men. 

Gonorrhoea  of  the  vulva  begins  with  a  sensation  of  itching,  soon  fol- 
lowed by  intense  burning.  At  first  the  secretion  is  mucoid  and  in 
excess  of  the  normal  fluid  of  the  parts  ;  it  then  becomes  mucopurulent, 
and  finally  of  a  glairy,  purulent  character.  Examination  usually  shows, 
particularly  in  hospitals  and  dispensaries,  and  often  in  private  practice, 
matting  of  the  hairs  on  the  mons  Veneris  and  of  the  hairs  on  the  labia 
majora  in  the  form  of  little  tufts.  Upon  separation  the  greater  and 
lesser  labia  are  seen  to  be  very  red,  much  swollen,  with  more  or  less 
superficially  eroded  areas,  and  in  the  reflections  of  the  mucous  mem- 
brane. The  whole  surface  is  bathed  with  a  creamy  pus,  which  stains 
and  stiffens  the  drawers  and  back  portion  of  the  chemise  in  spots. 
Perhaps  there  may  be  erythematous  or  even  eczematous  patches  on  the 
upper  and  inner  coapted  surfaces  of  the  thighs,  from  the  irritation  of 
the  discharge  which  has  flowed  over  them,  and  which  may  even  severely 
irritate  the  anus.  In  uncleanly  subjects  the  retention  and  decomposition 
of  the  discharge  give  rise  to  a  characteristic  nauseating  and  disgusting 
odor.  When  the  inflamed  surfaces  have  been  carefully  bathed,  numerous 
minute  follicular  elevations,  many  perhaps  superficially  eroded,  may  be 
seen,  mostly  on  the  labia  minora,  but  also  on  the  labia  majora.  Unless 
appropriate  treatment  is  instituted,  the  swelling  becomes  very  great,  the 
eroded  surfaces  become  larger  and  coalesce,  and  in  consequence  of  the 
swollen  condition  examination  of  the  urethra  and  vulva  is  very  difficult 
and  painful.  In  cases  of  long  labia  minora  the  swelling  is  sometimes 
so  great,  and  the  constriction  offered  by  the  labia  majora  is  so  firm,  that 
strangulation  seems  imminent.  This  condition  has  been  considered  by 
some  authors  as  analogous  to  paraphimosis  in  the  male,  while  others 
think  that  acute  vulvitis  is  the  analogue  of  balanitis  and  balanoposthitis. 
The  inflammatory  process  may  be  thus  intense,  and  yet  limited  to  the 


INFLAMMATION  OF  SKENE'S   URETHRAL   GLANDS.  159 

vulva ;  and,  although  the  urethral  and  vaginal  orifices  are  red  and 
inflamed,  these  canals  may  yet  remain  unaffected.  Thus  it  is  that  urina- 
tion is  excruciatingly  painful,  particularly  when  the  urine  runs  over  the 
vestibule,  vaginal  orifice,  and  fourchette,  and  that  digital  or  instru- 
mental examination  is  rendered  impossible. 

Taking  all  its  features  into  consideration,  gonorrhoea  of  the  vulva  of 
the  severe  form  is  a  distressingly  painful  affection.  Its  heat,  attendant 
itching,  and  burning  give  rise  to  erotic  desires,  even  to  nymphomania, 
while  handling  or  manipulation  of  the  parts  or  sexual  intercourse  is 
utterly  impossible.  Not  uncommonly,  the  irritation  of  the  anal  orifice 
by  the  escaping  discharge  gives  rise  to  tenesmus,  diarrhoea,  and  even 
incontinence  of  the  rectum.  Such  patients  are  frequently  forced  to 
assume  the  recumbent  position,  since  sitting  and  walking  are  attended 
by  increased  pain.      Occasionally  malaise  with  mild  fever  is  noticed. 

Arising  as  it  does  from  aborted  and  perhaps  violent  attempts  at 
coitus  in  rape,  in  mediate  contagion  from  gonorrhoeal  pus,  the  date  of 
the  onset  of  vulvar  gonorrhoea  is  very  often  clearly  marked.  The 
evolution  of  the  affection  is  rapid,  and  but  one  or  two  days  may  elapse 
from  the  time  of  the  commencement  of  the  premonitory  pruritic 
burning  sensation  to  its  full  development.  The  course  is  entirely 
dependent  upon  the  efficiency  and  vigor  of  treatment.  In  dispensary 
practice  it  is  often  very  difficult  to  make  these  girls  give  themselves 
proper  care.  Hence  this  affection  in  the  lower  classes  often  runs  on 
into  a  chronic  condition.  In  many  of  these  cases  the  inflammation 
settles  itself  in  the  cleft  between  the  large  and  small  labia  and  around 
the  introitus  vagina?.  In  private  practice  patients  are  more  attentive  to 
treatment,  and  then  the  severity  of  the  trouble  subsides  in  about  a  Meek 
or  ten  days.  Becoming  subacute,  it  then  may  rapidly  subside  and  dis- 
appear. 

In  acute  gonorrhoea  of  the  vulva  there  is  frequently  invasion  of  the 
urethra,  and  in  some  cases  the  infection  extends  into  the  vagina.  Not 
uncommonly  Bartholin's  glands  are  attacked,  and  rather  less  frequently 
Skene's  glands  and  the  peri-urethral  glands  may  become  implicated. 
These  complications  naturally  prolong  the  course  of  the  inflammation. 

There  is  a  chronic  form  of  vulvitis,  which  consists  in  an  inflamma- 
tion of  the  sebaceous  and  mucous  follicles,  which  may  or  may  not  be  of 
gonorrhoeal  origin.  Examination  of  the  parts  shows  a  large  or  small 
number  of  minute  red  follicular  elevations  seated  on  the  inner  surface 
of  the  labia  majora  and  minora. 

Inflammation  of  Skene's  Urethral  Glands. 

Skene's  glands,  which  open  a  little  within  the  orifice  of  the  urethra, 
may  be  the  seat  of  a  mild  form  of  inflammation  which  causes  the  patient 


160  GONORRHOEA   IN  THE  FEMALE. 

very  little  discomfort.  The  orifices  are  seen  to  be  enlarged,  and  around 
them  is  a  thin  rim  of  redness.  A  more  severe  condition  is  sometimes 
seen  in  which  there  is  active  inflammation  of  the  ducts  and  the  sur- 
rounding tissues,  and  the  escape  of  a  purulent  fluid.  In  this  condition 
the  meatus  is  so  swollen  that  it  is  somewhat  prolapsed  and  everted,  and 
thus  it  happens  that  the  orifices  of  the  ducts  are  rendered  visible  and 
look  like  little  yellowish-gray  ulcers  seated  on  a  deep-red  papillomatous 
base. 

Inflammation  of  Vestibulo vaginal  Glands. 

Gonorrhoeal  inflammation  may  also  attack  two  goodly  sized  glands, 
known  to-day  as  the  vestibulovaginal  bulbs,  the  orifices  of  which  open 
on  each  side  of  the  meatus,  and  perhaps  a  little  distance  from  it,  but  on 
its  lower  border  near  the  vagina.  This  affection  rapidly  passes  from 
the  acute  to  the  chronic  stage,  in  which  it  may  linger  for  long  periods. 
On  examination  we  find  a  red  elevation,  which  may  be  covered  with 
pus  or  from  which  a  little  pus  may  exude  on  pressure.  This  lesion 
may  escape  detection  unless  very  scrutinizing  search  is  made  for  it. 
Women  frequently,  before  coming  to  the  surgeon,  wash  the  parts  or  in 
urination  the  secretion  is  carried  away.  When  by  careful  pressure  the 
orifice  of  the  gland  is  detected,  the  passage  of  a  fine  probe  to  the  depth 
of  half  an  inch  or  more  Avill  show  the  source  from  which  the  suppura- 
tion comes.  It  can  readily  be  understood  that  such  a  chronic  lesion 
might  be  a  persistent  source  of  infection  in  men,  since  it  is  not  uncom- 
mon for  it  to  undergo  exacerbations. 

These  glands  may  rather  rarely  become  the  seat  of  abscess. 

Gonorrhoeal  Folliculitis. 

Around  the  urethra  for  the  distance  of  a  third  or  half  an  inch  a 
number  of  small  follicles  open  by  means  of  very  minute  ducts.  These 
follicles  may  become  inflamed  during  acute  or  chronic  gonorrhoea  and 
in  women  with  simple  vaginal  discharges.  These  little  foci  of  inflam- 
mation, of  which  there  may  be  as  few  as  two  and  as  many  as  ten,  are 
very  apt  to  escape  observation,  for  the  reason  that  they  do  not  present 
a  striking  appearance.  They  simply  look  like  inflamed  pinhead-sized 
elevations,  on  which  perhaps  there  may  be  a  small  pus-crust.  They 
cause  the  patient  very  little  trouble  beyond  a  very  slight  sensation  of 
heat  and  pricking.  Pressure  on  the  parts  will  usually  cause  a  small 
quantity  of  pus  to  exude.  Then  a  very  fine  probe  may  be  inserted  for 
a  quarter  of  an  inch,  or  even  deeper,  into  the  orifice  thus  revealed. 
Unless  properly  treated,  these  peri-urethral  folliculites  of  women  may 
persist  indefinitely. 


INFLAMMATION  OF  BARTHOLIN'S  GLANDS.  161 

Para-urethral  Folliculitis. 

Scattered  over  the  vestibule,  at  the  distance  of  half  an  inch  or  a  little 
more  from  the  meatus  (according  to  the  natural  size  of  the  parts),  is  a 
number  of  mucous  follicles  which  may  be  affected  by  gonorrhoea  of 
the  urethra,  vulva,  or  vagina.  These  follicles,  when  inflamed,  look  like 
small  red  papilla?,  from  which,  upon  pressure,  a  little  mucopus  or  pus 
will  exude.  Unless  cured,  these  lesions  may  remain  in  a  chronic  and 
indolent  condition,  and  they  may  end  in  sinuses  or  in  true  fistula?. 
These  fistula?  may  end  in  the  urethra  near  the  meatus  or  farther  down 
the  urethral  canal.  They  also  may  extend  toward  the  vagina  in  an 
incomplete  form,  or  they  may  open  into  that  tube. 

Around  the  fourchette  and  near  the  posterior  wall  of  the  vagina  a 
number  of  mucous  follicles  are  seated,  and  they  are  sometimes  invaded 
by  the  gonorrheal  process.  These  lesions  look  like  small  red  swellings, 
from  which,  on  pressure,  a  little  pus  may  exude.  These  follicular 
inflammations  are  very  chronic  in  character  and  rebellious  to  treatment. 
They  may  result  in  sinuses  and  fistula?.  In  some  cases  the  sinus  or 
fistula  extends  toward  the  vagina,  and  in  others  toward  the  rectum.  As 
a  result,  therefore,  there  may  be  vulvovaginal  or  vulvorectal  fistula?. 
These  fistula?  are  usually  very  small,  they  cause  little  trouble  during 
long  periods  of  time,  and  frequently  are  unrecognized  for  years. 

Many  cases  of  genital  folliculitis  in  women  will  be  met  in  which 
absolutely  no  history  of  gonorrhoea  can  be  obtained. 

Inflammation  of  Bartholin's  Glands. 

Bartholin's  or  the  vulvovaginal  glands  are  situated  one  on  either 
side  of  the  entrance  to  the  vagina,  in  the  triangular  space  bounded  by 
the  ascending  ramus  of  the  ischium,  the  vaginal  orifice,  and  the  trans- 
versa perina?i  muscle,  and  are  covered  by  the  superficial  perineal  fascia 
and  some  fibres  of  the  constrictor  vagina?.  They  are  conglomerate 
glands,  having,  when  fully  developed,  a  diameter  of  six-tenths  of  an 
inch.  The  ducts  of  these  glands  are  about  six  lines  in  length,  and 
they  open  just  in  front  of  the  hymen  near  the  lateral  and  posterior 
caruncula?  myrtiformes.  These  glands  pour  out  in  coitus  and  on  genital 
excitation  a  copious  secretion  of  albuminous  fluid,  which  lubricates  the 
vulva  and  the  vagina.  The  vulvovaginal  glands  may  be  the  seat  of 
two  forms  of  inflammation — the  one  simple,  and  the  other  gonorrhoeal. 

Simple  acute  Bartholinitis  is  mostly  seen  in  young  girls,  married  or 

single,  and  generally  follows  early  efforts  at  coitus.     In  many  cases  it 

results  from  the  violence  attendant   upon  rape.     In   some  cases  the 

simple  rupture  of  the  hymen  causes  local  irritation,  and  as  a  result  one 

or  both  vulvovaginal  glands  become  inflamed.     Its  frequence  in  very 
n 


162  GONORRHCEA   IN  THE  FEMALE. 

young  married  women  has  caused  it  to  be  called  "  the  bride's  abscess." 
It  is  particularly  liable  to  develop  in  girls  who  have  leucorrhoea  and 
who  are  not  careful  as  to  the  cleanliness  of  the  genital  parts.  It  some- 
times results  from  excessive  coitus  and  also  from  masturbation. 

The  symptoms  are  usually  quite  strongly  marked.  The  patient 
complains  of  pain  or  soreness  in  the  vulva,  and  inspection  reveals  a 
small  rounded  swelling  at  the  lower  or  posterior  third  of  the  vaginal 
orifice.  This  swelling  rapidly  increases  until  it  may  reach  the  size  of  a 
quite  small  egg.  Then  the  labium  major  becomes  pear-shaped  and  is 
pushed  outward,  and  we  see  a  deep-red  rounded,  fluctuating  swelling, 
which  may  extend  an  inch  and  even  more  from  the  level  of  the  vaginal 
orifice.  The  parts  are  the  seat  of  a  throbbing,  dragging  pain,  and  are 
exquisitely  sensitive  to  the  touch.  In  this  condition,  in  severe  cases, 
the  patients  can  neither  walk,  stand,  nor  sit.  They  have  chills,  malaise, 
and  febrile  movement.  In  some  cases  there  is  spontaneous  rupture 
through  the  duct,  but  in  most  cases  it  is  necessary  to  incise  the  abscess. 
Sometimes  it  bursts  spontaneously,  most  commonly  near  the  glandular 
outlet,  and  rarely  over  the  convexity  of  the  tumor.  The  pus  is  usually 
thick  and  yellow,  but  it  may  be  thin  and  serous.  Exceptionally,  it  has 
a  fetid  odor.  In  most  cases,  after  incision  into  or  bursting  of  the 
abscess,  the  parts  heal  and  the  gland  seems  to  return  to  its  natural 
condition.  In  some  cases,  however,  after  abscess-formation  and  pus- 
extrusion  have  taken  place,  the  gland  seemingly  returns  to  its  normal 
state;  yet  exacerbations  and  relapses  are  liable  to  occur.  Thus,  after 
menstruation  the  gland  may  swell  and  become  painful,  and  in  this  con- 
dition it  may  remain  a  little  time,  and  then  subside.  Such  exacerba- 
tions as  these  may  be  very  frequent,  and  they  keep  the  patients  in  a 
continuous  state  of  dread.  Excessive  venery,  masturbation,  and  leucor- 
rhoeal  discharges  may  also  light  up  the  suppurative  process,  with  all  its 
local  and  general  disturbances.  As  the  interval  of  time  between  ex- 
acerbations becomes  longer  the  tendency  to  them  seems  to  lessen,  and 
generally  it  dies  out ;  but  it  is  not  uncommon  to  see  a  woman  suffer 
from  acute  Bartholinitis  several  years  after  her  first,  second,  or  third 
experience. 

Usually  but  one  gland  is  affected,  and  most  commonly  it  is  the  left 
one.  The  affection  may,  however,  occur  bilaterally.  In  all  probability 
the  simple  form  of  Bartholinitis  is  caused  by  pus-cocci  acting  upon  a 
bruised  or  hyperasmic  part  thus  rendered  susceptible  to  infection. 

During  the  course  of  gonorrhoea,  acute  or  chronic,  the  ducts  of  Bar- 
tholin's glands,  or  the  glands  themselves,  may  be  the  seat  of  a  suppu- 
rating inflammation.  Of  late  years  there  has  been  a  tendency  to  mag- 
nify the  frequency  of  occurrence  of  these  complications  of  gonorrhoea  in 
women.     In  acute  gonorrhoea  the  duct  and  the  gland  itself  are  some- 


SIMPLE   VULVITIS.  163 

times  the  seat  of  inflammation.  In  chronic  gonorrhoea  it  is  more  com- 
mon to  find  only  the  duct  or  the  ducts  involved. 

Gonorrhceal  inflammation  of  the  duct  of  the  vulvovaginal  glands 
may  be  attended  with  very  mild  symptoms  of  heat  and  pricking,  and 
these  may  be  wholly  absent.  On  inspection  we  find  the  opening  of 
these  ducts  red  and  a  little  swollen ;  the  red  spots  thus  produced  are 
called  "  maculae  gonorrhoeica."  Pressure  on  the  parts  against  the  ramus 
of  the  ischium  causes  a  drop  of  milky  or  greenish  pus  to  exude.  In 
some  cases  this  localized  inflammation  is  the  only  remnant  of  the  gon- 
orrhceal process.  It  causes  little  or  no  discomfort,  so  that  frequently 
the  patient  does  not  know  that  she  has  such  a  trouble.  In  this  indolent 
condition  it  may  remain  for  long  periods,  or  it  may,  as  a  result  of  excit- 
ing and  irritating  causes,  become  acute.  The  body  of  the  gland  may 
become  infected,  in  which  event  there  may  be  acute  suppuration,  but 
usually  the  condition  is  rather  indolent  and  subacute.  The  gland  swells 
to  the  size  of  a  nutmeg  or  walnut,  and  may  be  grasped  and  its  contour 
clearly  made  out  between  the  finger-tips.  The  swelling  presents  a 
smooth,  quite  firm  structure  of  roundish  or  oval  outline.  Not  infre- 
quently the  duct  of  the  gland  can  be  felt  like  a  firm  round  cord. 
Pressure  causes  whitish  pus  to  exude.  This  condition  of  affairs  is 
found  in  prostitutes,  especially  in  old  ones.  It  is  the  cause  of  much 
trouble  and  worry  to  them,  since  they  are  always  in  dread  of  a  recru- 
descence of  the  acute  inflammation,  which  may  result  from  sexual  ex- 
cess or  any  inflammation  about  the  genitals    or  in  the  pelvic  cavity. 

Gonorrhoea  of  the  Tubes,  Ovaries,  and  Peritoneum. — When  gon- 
orrhoea ascends  and  passes  from  the  uterus  to  the  tubes  and  beyond,  the 
case  then  enters  the  domain  of  the  gynecologist. 

VULVOVAGINITIS   IN   INFANTS   AND   YOUNG    CHILDREN. 

Simple  Vulvitis. 

This  form  may  be  found  in  very  young  infants  and  in  children  from 
two  years  onward,  and  exceptionally  even  up  to  puberty. 

The  attention  of  the  mother  is  first  called  to  the  trouble  by  the  cries 
of  the  child  on  urination  and  by  the  frequency  of  the  act.  Exami- 
nation shows  the  vulva  alone  to  be  involved,  or  this  part  and  the  ure- 
thra together,  or  these  external  parts  and  the  vagina  are  found  affected. 

If  there  is  simple  vulvitis,  we  find  redness  and  swelling  of  the 
nymphae  and  the  labia  majora  (as  much  of  them  as  is  developed),  and  at 
first  a  sero-epithelial  secretion  looking  like  milk,  then  later  on  a  muco- 
purulent discharge.  The  surface  of  the  mucous  membrane  is  eroded  in 
minute  spots  and  goodly  sized  patches.  The  child's  pain  is  then  mainly 
caused  by  the  scalding  sensations  caused  by  the   urine  lodging  on  the 


164  GONORRHCEA  IN  THE  FEMALE. 

excoriated  surface.  Spontaneous  pain  may  result  from  the  vulvar 
inflammation. 

Another  form  of  simple  vulvitis  consists  in  moderate  heat,  redness, 
and  swelling  of  the  parts,  from  which  pus  or  mucopus  exudes.  Thus 
there  are  in  these  young  infants  two  forms  of  vulvitis — the  one  mild 
and  ephemeral,  with  a  sero-epithelial  discharge  moderate  in  quantity; 
and  the  other  more  severe  and  attended  with  greater  inflammation  and 
a  mucopurulent  discharge. 

Care  and  proper  medication  will  soon  cure  these  conditions.  When, 
however,  cases  are  neglected  the  morbid  process  extends  to  the  con- 
tiguous parts. 

Vulvovaginitis. 

This  affection  is  found  in  very  young  infants  and  in  children  from 
two  to  thirteen  years  old. 

In  infants  vulvovaginitis  usually  begins  as  a  vulvitis,  which,  being 
uncared  for,  becomes  more  intense  and  spreads  either  to  the  vagina  or 
to  the  urethra,  or  to  both.  As  a  result  there  is  produced  a  very  formid- 
able affection  for  such  a  young  subject.  In  many  cases  the  urethra  is 
not  infected,  but  there  seems  to  be  a  tendency  for  the  morbid  process  to 
extend  through  the  hymeneal  introitus,  and  to  involve  the  vagina  and 
perhaps  the  cervix  uteri. 

Examination  shows  a  reddened,  eroded  surface  of  the  vulva,  hymen, 
and  vagina.  A  copious  purulent  or  mucopurulent  secretion  escapes 
from  the  parts,  and  it  may  dry  in  crusts  on  the  labia  majora  or  even  on 
the  thighs.  The  pus  may  be  thin,  and  again  thick,  even  to  being  so 
gelatinous  that  it  can  be  taken  up  by  the  forceps.  In  this  condition  the 
infant's  sufferings  are  quite  severe. 

The  tendency  of  the  disease  is  to  persist  unless  proper  treatment  is 
adopted  ;  and  even  then  it  may  run  on  for  months  and  end  in  a  mild  and 
chronic  catarrhal  process.  When  the  urethra  is  involved  the  child's 
sufferings  are  much  increased. 

When  simple  vulvovaginitis  attains  a  very  severe  grade  of  intensity, 
it  is  practically  impossible  to  diagnosticate  it  from  the  so-called  gonor- 
rhceal  form.  It  will  be  seen  later  that  the  microscope  often  gives  us 
very  little  aid. 

Gonorrhoeal  Vulvovaginitis. 

It  must  be  distinctly  understood  that  vulvovaginitis  is  very  rarely 
of  venereal  origin  ;  and  that,  if  the  suppuration  does  originate  in  gonor- 
rhoeal pus,  the  infection  in  most  cases  takes  place  in  an  indirect  manner 
through  some  medium  or  agent. 

Since  so  little  is  really  known  as  to  the  mode  of  origin  of  this  form 


GONORRHEAL    VULVOVAGINITIS.  165 

of  vaginitis,  and  as  its  onset  is  unlooked  for  and  insidious,  the  affection 
is  well  on  in  its  course  before  it  is  seen  by  the  surgeon.  We  have  no 
precise  data  as  to  the  period  of  incubation,  but  we  are  warranted  in 
assuming  that  the  morbid  process  begins  in  mild  and  localized  hyper- 
emia. When  first  seen  these  children  present  the  evidence  of  suffering 
in  their  uneasiness  and  their  cries.  When  the  cervix  uteri  is  involved 
they  also  suffer  from  bellyache.  We  find  an  intensely  red  and  tumefied, 
superficially  eroded,  and  even  bleeding  condition  of  the  vulvar  struct- 
ures of  the  introitus  vaginae,  of  the  vagina  itself,  and  also  of  the  cervix 
uteri,  from  which  pus  may  drip.  A  profuse  yellowish-green  discharge 
escapes  from  the  hymeneal  orifice  and  is  found  smeared  over  the  vulva. 
Very  often  this  pus  dries  into  crusts  upon  the  labia  majora  and  upon 
the  inner  surface  of  the  thighs.  There  is  very  often  intertrigo,  even  of 
a  severe  type,  on  the  latter  regions.  When  the  urethra  is  involved 
urination  is  frequent  and  painful.  Then  when  the  urine  flows  over  the 
inflamed  vulva  the  child's  sufferings  are  great. 

Course. — The  course  of  the  affection  is  dependent  upon  the  care  given 
the  child  and  the  nature  of  the  treatment  adopted.  Under  the  most 
favorable  conditions  the  affection  is  often  very  obstinate,  and  in  neglected 
or  insufficiently  cared-for  infants  it  runs  on  indefinitely  if  unchecked. 
If  a  child  afflicted  with  this  disease  is  cured  in  two  or  three  months, 
the  result  may  be  pronounced  brilliant.  In  very  many  cases  the  dis- 
ease runs  on  and  ends  in  a  chronic  catarrhal  condition. 

There  can  be  no  question  as  to  the  infectious  quality  of  pus  derived 
from  this  disease,  since  there  are  many  cases  on  record  in  which  it  has 
produced  severe  vulvovaginitis  and  also  intense  purulent  ophthalmia, 
which  as  a  complication  of  the  disease  stands  first.  This  form  of  the 
affection  is  seen  in  babes  in  the  arms  and  in  children  from  two  to 
ten  years  old.  In  families  we  see  sporadic  outbreaks,  and  in  hospitals 
and  maternities  more  or  less  severe  and  extensive  epidemics. 

Gonorrhoeal  rheumatism  is,  according  to  statistics,  a  rather  rare  com- 
plication of  purulent  vulvovaginitis. 

Etiology. — In  the  cases  of  young  infants  it  is  often  impossible  to 
learn  any  facts  as  to  the  source  of  infection. 

Usually  infants  are  brought  suffering  from  vulvovaginitis  when  they 
are  some  weeks  or  months  old.  In  very  many  instances  the  only  assump- 
tion warranted  is  that  the  more  or  less  severe  process  began  in  the  phys- 
iological hyperemia  which  is  constantly  present  in  young  children.  In 
the  absence  of  negative  proof  it  may  be  confidently  asserted  that  many 
cases  of  this  affection  originate  de  novo,  without  the  implantation  of  an 
infectious  secretion. 

Undoubtedly,  many  infants  are  infected  by  some  means  from  pus 
from  the  vag-inse  of  their  mothers  or  nurses.     I  have  heard  of  mothers 


166  GONORRHCEA    IN  THE  FEMALE. 

and  nurses  who  quieted  their  infants  and  charges  by  placing  a  finger  in 
the  vulva,  and  I  can  understand  that  a  soiled  finger  might  carry  infec- 
tion. Then,  again,  sponges  used  by  mothers  suffering  from  leucorrhoea 
have  also  been  used  upon  their  infants,  who  became  affected  with  vulvo- 
vaginitis. 

When  the  child  of  poverty  and  squalor  gets  out  of  arms  and  sleeps 
and  mingles  with  older  girls  and  women,  it  is  liable  to  contract  vulvo- 
vaginitis accidentally,  conveyed  by  means  of  infected  fingers  and  mainly 
by  soiled  underwear,  sponges,  and  towels.  From  one  suffering  child 
other  members  of  the  family  or  its  playmates  may  be  infected  in  the 
vulva  or  the  eyes  by  either  the  simple  catarrhal  or  the  so-called  gonor- 
rheal form  of  the  disease. 

Among  older  girls  direct  gonorrhoea!  infection  may  occur  as  a  result 
of  attempted  or  complete  coitus  with  young  boys.  There  are  many  such 
instances  in  medical  literature.  Then,  again,  infection  may  occur  among 
several  or  many  young  girls  through  their  own  bad  habits. 

Succinctly  stated,  the  truth  of  the  question  of  etiology  is  this  :  In 
many  cases  the  clinical  history  and  microscopic  picture  establish  a  diag- 
nosis of  simple  catarrhal  vulvovaginitis  ;  in  other  cases  the  clinical  and 
microscopical  evidence  points  clearly  to  gonorrhoea ;  but  in  still  other 
cases,  though  the  symptom-complex  is  complete  and  the  microscopical 
picture  points  to  gonorrhoea,  absolutely  no  evidence  can  be  obtained  to 
prove  that  the  disease  has  had  a  venereal  origin  or  has  originated  in 
gonorrhoeal  pus.  On  the  other  hand,  all  facts  point  to  the  suppuration 
having  begun  in  a  simple  catarrhal  form,  and  by  reason  of  dirt  and 
uncleanliness  has  assumed  all  the  features  of  a  severe  gonorrhoeal  inflam- 
mation. I  am  clearly  of  the  opinion  that  in  many  cases  which  have 
been  regarded  as  undoubtedly  of  gonorrhoeal  nature  the  morbid  process 
originated  de  novo  in  a  simple  catarrhal  process. 

There  can  be  no  doubt  that  onanism,  the  eruptive  fevers,  seat-worms, 
pediculi,  eczema,  and  perhaps  impetigo  and  herpes,  act  simply  as  con- 
tributory causes.  They  establish  a  low  form  of  irritative  process,  and 
thus  render  the  tissues  susceptible  to  microbic  invasion  and  inflamma- 
tion, while  dirt,  the  exposed  condition  of  the  parts,  unremoved  dis- 
charges, and  general  uncleanliness  and  want  of  care  combined  con- 
tribute to  the  production  of  a  very  formidable  suppurative  process. 

Treatment  of  Gonorrhoea  in  the  Female. — In  the  treatment  of 
gonorrhoea  in  the  female  the  prime  essentials  are  scrupulous  cleanliness, 
copious  antiseptic  injections  and  flushings,  and  constant  care  as  to 
details.  The  patient  should  be  made  to  understand  clearly  the  gravity 
of  the  disease,  and  its  tendency  to  continued  upward  extension  and  to 
localize  itself  in  the  recesses  and  crypts  of  the  genitalia  ;  and  she  should 
be  urged  to  continue  under  observation  until  she  is  pronounced  cured 


GONORRHEAL    VULVOVAGINITIS.  167 

by  the  surgeon.  It  is  the  duty  of  the  latter  to  make  thorough  and 
painstaking  examinations  of  the  whole  genito-urinary  tract,  and  to 
acquaint  himself  with  the  full  extent  of  the  disease.  The  various  mor- 
bid secretions  should  be  examined  by  means  of  the  microscope  with  a 
high-power  lens  and  oil-immersion. 

In  acute  cases  the  recumbent  position  should  be  insisted  upon.  The 
diet  should  be  of  the  simplest  character,  and  preferably  of  milk.  A 
brisk  cathartic  may  be  given,  and  throughout  the  course  of  the  disease 
one  or  more  full  movements  of  the  bowels  should  occur  each  day. 

Treatment  of  Gonorrhoea  of  the  Vulva. — For  gonorrhoea  of  the 
vulva,  with  all  its  painful  accompaniments  in  the  acute  stage,  very  hot 
sitz-baths,  repeated  four  or  more  times  daily  if  possible,  should  be  used, 
taking  care  that  the  water  is  brought  into  free  contact  with  the  whole 
surface  affected.  Very  often  the  itching  and  burning  are  much  allaved 
by  affusions  of  hot  alkaline  solutions  (powd.  borax  or  supercarbonate  of 
soda,  3ij  to  water  §xxxij),  to  which  may  be  added  two  to  four  drachms 
of  wine  of  opium  or  laudanum.  Lead-and-opium  lotion  may  also  be 
used.  With  this  may  be  saturated  pledgets  of  lint  or  of  absorbent 
gauze,  which  should  be  carefully  and  thoroughly  applied  to  the  surfaces 
in  order  to  keep  them  apart,  and  renewed  very  frequently,  since  they 
soon  become  saturated  with  pus.  So  soon  as  the  vulvar  orifice  will 
permit,  a  soft  catheter,  No.  15  F.,  or  the  long  tube  of  a  Davidson  or 
fountain  syringe,  should  be  introduced  as  far  as  it  will  go,  and  several 
copious  injections  of  very  hot  alkaline  water  should  be  made  every  day. 
As  the  inflammation  declines  it  may  be  necessary  to  paint  the  parts  to 
their  smallest  recesses  with  a  solution  of  nitrate  of  silver,  thirty  grains 
to  the  ounce  of  water,  followed  by  hot  ablutions  with  a  solution  of  com- 
mon salt.  After  a  very  hot  sitz-bath  the  lead-opium-and-borax  lotion 
may  again  be  applied.  In  twenty-four  hours  after  this  application  to 
the  old  or  the  young  much  improvement  will  be  noted  in  the  lessened 
oedema  and  redness  and  in  a  less  painful  condition.  Then  a  1  per  cent, 
solution  of  alum,  with  laudanum,  may  be  used ;  and  later  on  the  parts 
may  be  dusted  with  subnitrate  of  bismuth  or  powdered  boracic  acid 
on  a  pledget  of  lint  or  absorbent  gauze. 

When  the  inflammation  is  on  the  wane  the  parts  may  be  carefully 
swabbed  with  a  solution  of  nitrate  of  silver  1  :  100,  which  may  be 
gradually  increased  in  strength  to  5  :  100.  After  each  swabbing  the 
soothing  remedies  already  mentioned  may  be  used  continuously. 

Treatment  of  Gonorrhoea  of  the  Urethra. — Vulvar  gonorrhoea 
is  very  frequently,  sooner  or  later,  accompanied  witli  implication  of 
the  urethra  and  increase  in  the  patient's  sufferings.  The  solution 
of  bicarbonate  of  potassa  with  hyoscyamus  recommended  for  acute 
gonorrhoea  of  the  male  may  be  given  in  order  to  neutralize  the  acidity 


168  GONORRHCEA   IN  THE  FEMALE. 

of  the  urine;  and  diluent  drinks,  such  as  flaxseed  and  slippery-elm 
teas  and  barley-water,  may  be  taken  ad  libitum.  As  soon  as  the 
inflammation  in  the  urethra  has  somewhat  subsided  from  the  use  of  the 
foregoing  measures  suitable  for  the  acute  stage  of  vulvitis,  intra-urethral 
injections  of  very  hot  water  with  borax  or  boracic  acid,  siij  to  ^xxxij, 
frequently  made  by  means  of  any  recurrent  syringe  or  catheter,  or 
preferably  by  means  of  Skene's  reflux  catheter,  may  be  used.  As  the 
inflammation  subsides,  intra-urethral  injections  of  hot  water,  containing 
carbolic  acid  in  the  proportion  of  -^  of  1  per  cent.,  are  very  beneficial. 
In  many  instances  where  the  pain  on  urination  is  very  great  the  instil- 
lation into  the  urethra  of  a  solution  of  opium  in  glycerin,  or  of  cocaine 
muriate  in  glycerin  and  water,  by  means  of  a  small  cylindrical  drop- 
ping-pipe,  is  followed  by  marked  relief.  As  the  urethral  lesion  further 
declines,  a  2  per  cent,  solution  of  nitrate  of  silver  may  be  injected  as 
far  down  the  urethra  as  possible,  since  it  is  commonly  involved  in  its 
whole  length  ;  or  a  thirty-grain-to-the-ounce  solution  of  nitrate  of  silver 
may  be  carefully  and  sparingly  applied  by  means  of  an  applicator  facili- 
tated by  the  endoscope  or  a  Sims  fenestrated  speculum.  It  is  only  in 
the  subacute  and  chronic  stages  that  antiblennorrhagics  are  to  be  used, 
and  then  in  rather  smaller  doses  than  in  the  male.  In  some  cases  these 
agents  produce  marked  relief  in  the  symptoms  and  a  lessening  of  the 
discharge,  and,  again,  they  seem  to  be  of  no  benefit  at  all  ;  from  which 
it  follows  that  local  measures  are  always  the  most  certain. 

Treatment  of  Gonorrhoea  of  the  Vagina.— Gonorrhoea  of  the 
lower  part  of  the  vagina,  which  is  commonly  accompanied  with  the 
same  affection  of  the  vulva  and  perhaps  of  the  urethra,  should  be 
treated  on  the  principles  already  given.  As  soon  as  the  acute  symp- 
toms subside,  copious  irrigations  of  very  hot  water  well  into  the  canal 
should  be  made.  Then,  as  soon  as  the  irritability  of  the  parts  will 
permit,  the  surgeon  should  make  a  thorough  examination,  having  at 
his  command  a  perfect  light,  natural  or  artificial.  In  my  judgment, 
the  genupectoral  position,  though  objectionable  to  patients  from  feelings 
of  delicacy  and  by  reason  of  its  uncomfortableness,  is  by  far  the  best  by 
which  to  obtain  a  thorough  view  of  the  whole  vagina,  including  the 
cervix  uteri  and  the  posterior  and  the  anterior  fornix  vagina?.  The 
blade  of  a  Sims  speculum  carefully  introduced  elevates  the  posterior 
vaginal  wall,  and  free  inspection  is  possible. 

When  the  very  acute  symptoms  of  gonorrheal  vaginitis  have  begun 
to  subside,  the  inflamed  surfaces  may  be  carefully  and  thoroughly 
cleansed  by  means  of  a  cotton-holder.  Then  the  whole  surface  may  be 
exposed  by  the  wire  speculum,  and  then  gently  and  sparingly  touched 
with  a  thirty-grain-to-the-ounce  solution  of  nitrate  of  silver,  after  which 
the  canal  should  be  thoroughly  irrigated  with  hot  water  to  which  a 


GONORRHEAL    VULVOVAGINITIS.  169 

little  common  salt  has  been  added.  Another  and  less  commendable  and 
precise  way  of  applying  the  nitrate-of-silver  solution  is  to  pass  a  Fer- 
gusson  speculum  so  as  to  encircle  the  cervix  uteri,  which. is  touched 
with  the  solution  on  a  cotton-holder.  Then  one  or  two  drachms  of  it 
are  poured  into  the  speculum,  when,  on  withdrawal  with  a  rotary 
motion,  the  solution  will  come  in  contact  with  the  vaginal  walls.  After 
this  application,  which  should  be  thoroughly  made  in  the  posterior  and 
the  anterior  fornix,  and  also  to  the  uterus,  usually  as  far  as  the  os 
internum,  the  vagina  should  be  thoroughly  tamponed  with  iodoform 
gauze.  In  many  cases,  the  nitrate-of-silver  solution  having  been  ap- 
plied once  or  twice,  much  benefit  will  follow  the  deposition  deep  into 
the  vagina  of  a  considerable  amount  of  powdered  boracic  acid,  which 
should  be  retained  by  the  gauze  or  wood-wool  tampon.  Whatever  form 
of  tampon  is  used,  it  should  be  removed  with  great  care  every  twenty- 
four  or  forty-eight  hours,  and  then  copious  hot  boracic-acid  irrigations 
should  be  made.  The  frequency  and  strength  of  the  nitrate-of-silver 
applications  should  be  determined  by  the  progress  of  the  case.  Usually, 
several  days  should  elapse  before  a  second  application  is  made ;  and  if 
the  patient  is  under  control,  two  or  three  are  enough. 

Bichloride-of-mercury  irrigations  may  in  a  measure  allay  the  irrita- 
tion, but  they  generally  fail  to  produce  a  cure.  In  chronic  vaginitis 
extract  of  Pinus  canadensis  may  be  used  on  tampons. 

Treatment  of  Gonorrhoea  of  the  Os  and  Uterine  Cavity. — There 
is  no  form  of  gonorrhoea  in  women  that  demands  greater  skill,  judg- 
ment, and  conservatism  than  gonorrhceal  infections  of  the  os  and  uterine 
cavity.  In  these  delicate  parts  energetic  treatment  should  be  promptly 
instituted  in  order  to  prevent,  if  possible,  the  further  upward  spread  of 
the  infection.  Unfortunately,  the  general  practitioner  is,  as  a  rule, 
not  sufficiently  versed  in  the  course  of  the  disease  and  skilled  in  its 
handling  to  warrant  his  active  intervention  in  these  cases,  and  my 
advice  to  any  one  not  thus  equipped  is,  when  he  has  these  cases  under 
his  care,  promptly  to  call  in  the  aid  of  a  conservative  gynecologist. 

It  is  well  for  the  surgeon  to  bear  in  mind  that  in  these  cases  the 
disease  quickly  localizes  itself  deeply  in  the  mucous  membrane  of 
the  cervix,  and  then  assumes  a  chronic  condition,  which  at  any  time 
under  stimulation  may  become  acute.  To  treat  these  cases  properly 
the  os  must  be  dilated,  and  then  the  mucous  membrane  must  either  be 
curetted  or  to  it  must  be  applied  quite  strong  caustic  solutions  (chloride 
of  zinc  (LugoPs  solution)),  etc.  These  operations  should  be  done  witli 
special  skill  and  good  judgment  under  favorable  home  or  hospital  con- 
ditions, and  with  the  utmost  regard  for  asepsis  and  antisepsis.  Therefore 
I  say  that,  as  a  rule,  these  cases  do  not  belong  to  the  genito-urinary 
surgeon,  but  should  be  treated  by  men  well  versed  in  women's  <li-oases. 


170  QONORRHCEA   IN  THE  FEMALE. 

Treatment  of  Bartholin's  Glands. — In  the  treatment  of  abscess  of 
Bartholin's  glands  general  surgical  principles  should  prevail.  If  an 
incision  is  necessary,  it  should  be  freely  made  over  the  most  fluctuating 
part  of  the  tumor.  Then,  after  thorough  curetting  and  antiseptic  irri- 
gation, the  parts  should  be  well  packed  with  iodoform  gauze,  which 
when  the  inflammatory  symptoms  have  subsided  may  be  replaced  by 
balsam-of-Peru  gauze.  These  packings  should  be  carefully  applied 
until  full  healing  has  been  produced.  In  chronic  cases  it  is  good  sur- 
gery to  extirpate  the  gland  as  soon  as  possible,  since  it  is  almost  certain 
that  exacerbations  will  occur  sooner  or  later. 

Treatment  of  Folliculitis. — Whenever  the  anatomical  arrangement 
of  the  parts  will  allow  of  the  slitting  up  of  the  various  follicles  in  the 
vulva  and  urethra  when  the  seat  of  chronic  gonorrhoea,  this  little  opera- 
tion should  be  performed  with  all  antiseptic  care.  Then,  after  cauter- 
ization with  a  solution  of  nitrate  of  silver,  6  :  100,  by  means  of  an 
applicator  or  a  hypodermic  syringe  with  a  blunt-pointed  needle,  the 
little  cavity  should  be  packed  and  caused  to  heal  from  the  bottom. 
Sometimes  these  little  inflammatory  foci  cause  much  trouble  to  the  sur- 
geon, and  ultimately  it  is  necessary  to  extirpate  them. 

Treatment  of  Vulvovaginitis  in  Infants  and  Young-  Children. — 
The  first  duty  of  the  surgeon  in  all  cases  of  vulvovaginitis  is  to  insist 
upon  the  observance  of  absolute  cleanliness  of  the  infant,  of  its  clothes, 
and  of  its  surroundings.  The  next  is  the  enforcement  of  prophylaxis 
for  the  children  and  adults  of  the  family.  These  facts  must  be  vividly 
impressed  upon  the  mother  or  nurse,  or  upon  any  one  who  may  tempo- 
rarily care  for  the  child. 

In  hospitals  and  nurseries  a  child  should  be  isolated  immediately 
it  is  discovered  that  it  is  infected ;  and  if  possible  it  should  be  cared 
for  by  nurses  who  wait  on  it  alone.  A  nurse  having  charge  of  a  child 
thus  affected  should  not  be  allowed  to  care  for  other  non-affected  chil- 
dren. In  the  event  of  necessity,  when  a  special  nurse  cannot  be  detailed 
to  the  case,  she  should  be  thoroughly  instructed  as  to  how  not  to  carry 
infection  or  allow  it  to  occur  in  uninfected  children.  By  rigid  discipline 
the  spread  of  the  disease  (which  in  some  epidemics  is  like  wild-fire) 
may  be  limited  to  the  original  case  or  cases. 

The  desquamative  catarrhal  condition  of  the  genitals  of  new-born 
girls  may  be  treated  by  cleanliness,  by  free  injections  into  the  vagina  of 
warm  solutions  of  boric  acid  or  diluted  Goulard's  water,  followed  by 
cleanliness  and  dryness  of  the  parts,  obtained  by  means  of  some  dust- 
ing-powder. Whenever  it  is  possible  in  these  cases  a  pledget  of 
absorbent  cotton  should  be  placed  in  the  vulva,  and  it  should  be  fre- 
quently renewed. 

For  severe  cases  of  the  simple  and  so-called  gonorrhoea!  type  a  care- 


GONORRHEAL    VULVOVAGINITIS.  171 

fully  conducted,  methodical  treatment  is  necessary.  Very  thorough  irri- 
gation of  the  parts  with  a  warm  bichloride  solution  (1  :  6000  or  1  :  10,000) 
may  be  used  several  times  daily.  After  this  cleansing  process  the  vagina 
should  be  expanded  by  means  of  a  double-bladed  male  urethral  spec- 
ulum, and  the  parts  made  dry  by  absorbent  cotton  on  an  applicator. 
Then  a  10  per  cent,  nitrate-of-silver  solution  is  carefully  applied  to  the 
whole  inflamed  surface.  The  applications  should  be  made  by  the  sur- 
geon or  by  an  intelligent  nurse,  and  they  should  be  thorough.  Infants 
struggle  and  resist  when  any  mode  of  treatment  is  used,  so  it  is  neces- 
sary to  have  a  convenient  table,  good  light,  and  all  suitable  instruments 
and  appliances  ready  at  hand.  Alkaline  mixtures  containing  tincture 
of  hyoscyamus  may  be  given,  with  benefit,  to  relieve  the  burning  on 
urination. 

Iodoform  in  the  form  of  bougies  may  be  used,  but  there  is  no  cer- 
tainty of  good  resulting  from  it. 

Under  the  application  of  the  solution  of  nitrate  of  silver  benefit 
will  occur ;  and  it  will  be  observed  that  the  color  of  the  discharge  is 
transformed  from  a  greenish  to  a  grayish  milky  hue,  and  that  the 
gonococci  (if  found  in  the  course  of  the  case)  will  have  become  much 
less  numerous  in  the  specimens  examined.  In  this  event  the  treatment 
may  be  continued  by  means  of  warm  irrigations  of  nitrate  of  silver 
(1  or  2  :  2000),  given  once  or  twice  a  day.  In  almost  every  case  the 
cure  will  be  slow  and  exacerbations  may  be  expected,  and  the  patience 
of  the  surgeon  and  the  fortitude  of  the  mother  may  be  sorely  taxed.  Still, 
in  any  event,  care  must  not  be  relaxed  nor  should  the  treatment  be 
suspended. 


CHAPTER   X. 

STRICTURE  OF  THE  URETHRA. 

A  full  knowledge  of  chronic  anterior  and  posterior  urethritis  and 
of  their  pathological  anatomy  is  absolutely  essential  to  the  clear  com- 
prehension of  the  nature  and  course  of  stricture  of  the  urethra.  While 
true  gonorrheal  stricture  of  the  urethra  is  only  found  in  the  anterior 
part  of  the  canal,  it  is  very  essential  that  the  inflammatory  condition  of 
the  posterior  part  which  frequently  coexists  should  be  well  understood. 
It  is  necessary  to  emphasize  this  point,  since  nearly  all  authors  concern 
themselves  solely  with  the  morbid  changes  which  take  place  in  the 
anterior  urethra. 

It  has  been  shown  (see  page  74)  that  in  chronic  anterior  urethritis 
the  essential  lesion  is  a  more  or  less  extensive  small-cell  infiltra- 
tion into  the  submucous  connective-tissue  layer  and  a  chronic  catarrhal 
condition  of  the  mucous  membrane  itself.  These  pathological  conditions 
may  disappear,  perhaps  spontaneously  in  some  cases,  but  generally  as 
the  result  of  treatment.  On  the  other  hand,  when  this  localized  inflam- 
matory process  persists  for  a  very  long  time,  it  leads  to  certain  permanent 
cell-changes  which  materially  lessen  the  calibre  and  impair  the  dilata- 
bility  of  the  urethra  and  interfere  with  its  function. 

This  affection  is  a  rather  frequent  sequela  of  gonorrhoea,  and  it  also 
may  be  the  result  of  traumatism.  Certain  stenoses  of  the  urethra  in 
the  glans  penis  have  been  termed  congenital  strictures,  therefore  we 
broadly  divide  stricture  of  the  urethra  as  follows  :  congenital,  traumatic, 
and  gonorrhceal  stricture,  the  two  latter  being  acquired  forms.  Acquired 
stricture  of  the  urethra  may  be  defined  as  a  condition  of  the  canal 
attended  by  decidedly  well-marked  contraction  or  stenosis,  and  an  utter 
loss  of  normal  dilatability  caused  by  an  inflammatory  process  which 
produces  a  sclerosis  of  greater  or  less  density  and  contractile  power. 

The  male  urethra  is  a  membranous  canal  whose  walls  are  in  contact 
with  each  other,  and  is  composed  of  three  layers  :  1,  an  internal  layer 
of  mucous  membrane  ;  2,  a  submucous  connective-tissue  layer  ;  and  3,  a 
well  developed  muscular  layer  which  consists  of  circular  and  longi- 
tudinal fibres. 

The  urethra  is  for  purposes  of  description  divided  into  the  penile  or 
pendulous  portion,  which  extends  from  the  meatus  to  the  penoscrotal 
angle  ;  a  bulbous  portion,  which  is  the  continuation  up  to  the  triangular 
172 


STRICTURE  OF  THE   URETHRA.  173 

ligament ;  a  membranous  portion,  which  is  the  segment  seated  between 
the  two  layers  of  this  ligament,  and  a  prostatic  portion,  which  begins  at 
the  apex  of  the  prostate  and  extends  to  its  base. 

The  average  length  of  the  urethra  is  about  8£  inches,  of  which  the 
pendulous  portion  includes  6^  inches,  the  membranous  f  of  an  inch,  and 
the  prostatic  1^  or  1\  inches. 

The  calibre  of  the  urethra  varies  in  different  individuals,  and  is  not 
at  all  uniform  in  the  course  of  the  canal.  Taking  a  general  average, 
the  following  dimensions  may  be  accepted  as  correct  concerning  the 
calibre  of  the  urethra  in  its  various  portions : 

Meatus,  7  to  9  mm 21  to  28  F. 

Fossa  navicularis,  10  to  11  mm 30  to  33  F. 

Middle  of  pendulous  portion,  9  to  10  mm 27  to  30  F. 

Bulb,  11  to  12  mm 33  to  36  F. 

Membranous  urethra,  9  mm 27  F. 

At  apex  of  prostate,  10  mm 30  F. 

Middle  of  prostate,  15  mm 45  F. 

Vesical  end  of  prostate,  11  mm 33  F. 

It  is  a  safe  rule  to  take  30  French  as  the  average  normal  calibre  of 
the  urethra,  with  the  understanding  that  there  are  exceptional  cases, 
some  of  which  are  under  and  some  over  that  average. 

For  practical  purposes  it  is  well  to  further  divide  the  urethra,  follow- 
ing Thompson,  into  those  regions  which  may  be  the  seat  of  operation ; 
they  are  as  follows  :  Region  1,  which  includes  the  membranous  and  1 
inch  of  the  bulbous  urethra,  and  is  about  If  inches  long.  Region  2, 
which  begins  at  the  anterior  limit  of  region  1  and  extends  to  within  2^ 
inches  of  the  meatus,  being  nearly  3  inches  long ;  and  region  3,  which 
begins  at  the  meatus  and  includes  the  distal  2\  inches  of  the  urethra. 

The  great  majority  of  cases  of  stricture  are  found  in  Region  1,  while 
Regions  2  and  3  are  not  infrequently  affected. 

From  a  pathological  standpoint  stricture  may  be  divided  into  soft, 
semifibrous  and  modular  or  densely  fibrous  varieties. 

In  soft  stricture  the  round-cell  infiltration  around  the  canal  is  quite 
dense,  and  has  not  as  yet  undergone  fibrous  proliferation. 

In  semifibrous  stricture  more  or  less  of  the  cellular  exudation  has 
become  changed  into  fusiform  cells,  and  the  lesion  consists  of  a  general 
mingling  of  round-cell  exudation  with  young  fibrous  tissue. 

Inodular  stricture  is  the  direct  outcome  of  the  two  forms  just  men- 
tioned and  consists  of  a  circular  mass  of  true  fibrous  tissue  lined  with 
mucous  membrane.  Stricture-formation  may  be  limited  to  the  sub- 
mucous connective-tissue  layer,  but  it  may  involve  the  muscular  layer 
and  later  on  encroach  more  or  less  upon  the  corpus  spongiosum.  In 
the  bulbous  urethra  inodular  stricture  is  prone  to  develop  and  wholly 
replace  the  elastic  and  muscular  fibres  so  plentiful  in  this  region. 


174  STRICTURE   OF  THE   URETHRA. 

As  a  rule,  stricture-formation  is  confined  to  the  anterior  urethra  and 
particularly  the  bnlbo-membranous  junction  and  does  not  show  a  ten- 
dency to  pass  through  the  opening  in  the  triangular  ligament.  But  in 
some  rather  rare  cases  the  morbid  process  exceeds  the  usual  limit  and 
involves  the  membranous  urethra  in  part  or  totally.  It  is  safe  to  say 
that  gonorrhoea  does  not  produce  primary  stricture  of  the  membranous 
urethra.  Gonorrhceal  stricture  of  the  prostatic  urethra  has  never  been 
found. 

Causes  of  Stricture. — In  the  vast  majority  of  cases  gonorrhoea  is 
the  cause  of  urethral  stricture. 

In  somewhat  rare  cases  we  learn  from  a  patient  having  a  tight 
stricture  that  he  had  but  one  attack  of  gonorrhoea,  or  perhaps  two,  and 
that  the  disease  did  not  persist  very  long.  In  the  majority  of  cases  of 
stricture  there  is  a  history  of  repeated  recrudescence  of  an  original 
gonorrhoea  or  a  greater  or  less  number  of  new  infections. 

The  long  continuance  of  gonorrhoea  is  the  essential  cause  of  stricture 
rather  than  the  severity  of  the  attack. 

In  the  minds  of  the  laity  injections  play  an  important  part  in  the 
production  of  urethral  stricture.  This  view  has  no  foundation  in  fact, 
since  mild  injections  are  productive  of  some  good,  and  strong  and  severe 
ones  are  so  painful  in  their  effects  that  they  are  soon  given  up. 

In  some  rare  cases  stricture  of  the  meatus  has  been  caused  by  sclero- 
derma and  keloid  of  the  glans  penis. 

It  may  also  result  from  the  healing  of  chancres  and  chancroids  and 
of  phagedena  at  the  meatus. 

In  contradistinction  to  gonorrhceal  stricture  it  is  necessary  to  con- 
sider congenital  and  traumatic  strictures. 

Congenital  Stricture. 

Congenital  stricture  of  the  urethra  is  very  rare,  and  is  limited  to 
certain  cases  in  which  there  is  contraction  either  at  the  meatus  or  at  the 
distal  part  of  the  fossa  navicularis.  The  narrowing  of  the  meatus  is 
either  due  to  the  development  of  mucous  membrane  or  to  the  smallness 
of  the  orifice  in  the  glans  penis.  It  exists  in  various  degrees,  and  it 
may  be  as  small  as  a  pin-head  or  somewhat  larger.  In  many  cases  of 
children  difficulty  in  urination  is  experienced  as  a  result  of  this  stenosis. 

Cases  have  been  reported  in  medical  literature  in  which  strictures 
seated  in  the  pendulous  and  bulbous  urethra  have  been  thought  to  be 
of  congenital  origin,  but  their  histories  have  been  so  vague  and  unsatis- 
factory that  no  definite  conclusions  can  be  drawn  from  them.  Un- 
doubtedly in  some  instances  in  which  stricture  of  the  urethra  has  been 
found  in  young  boys  and  adolescents  without  a  history  of  recent  gonor- 
rhoea, the  morbid  process  began  in  early  life  as  a  result  of  non-specific 


TRAUMATIC  STRICTURE.  175 

or  specific  urethritis,  of  which  no  history  could  be  obtained.  In  some 
cases  traumatism  of  the  urethra  occurring  in  early  life  and  forgotten 
may  be  the  cause  of  stricture  in  young  subjects. 

Treatment. — The  directions  given  on  page  195  for  the  treatment  of 
contractions  and  strictures  at  the  meatus  Avill  apply  with  equal  force  to 
congenital  narrowing  of  this  orifice. 

Traumatic  Stricture. 

This  affection  occurs  as  a  result  of  blows,  kicks,  and  falls  upon  the 
perineum  on  such  articles  as  rails,  barrels,  pails,  joists,  and  chairs,  which 
cause  damage  to  the  urethral  canal.  The  injury  may  be  partial  when 
only  the  lower  portions  of  the  urethra  are  cut  through  ;  it  may  involve 
all  of  the  canal  except  the  upper  portions,  or  the  tear  may  involve  the 
whole  lumen  of  the  urethra.  In  most  cases  traumatic  stricture  occurs 
in  the  bulbous  urethra  without  damage  to  the  triangular  ligament,  but 
in  some  instances  this  structure  is  more  or  less  torn.  In  rather  excep- 
tional cases  the  membranous  urethra  is  the  seat  of  lesion,  and  in  very 
rare  ones  the  prostatic  urethra  is  damaged.  Rupture,  partial  or  com- 
plete, of  the  membranous  or  prostatic  urethra  is  generally  caused  by 
fracture  of  the  pelvis  and  also  by  crushing  blows  and  falls  upon  the 
perineum.  When  the  urethra  is  ruptured  in  the  bulbous  portion,  a 
large  purplish  swelling  is  soon  found  in  the  perineum  and  scrotum. 

Rupture  of  the  membranous  and  prostatic  urethra  may  not  be  at- 
tended by  any  visible  signs  beyond  perhaps  contusion  of  the  perineum, 
but  the  finger  in  the  rectum  will  clearly  make  out  a  goodly-sized,  pain- 
ful swelling  around  or  starting  from  these  segments  of  the  urethra. 

In  cases  of  rupture  of  the  bulbous  urethra  there  is  usually  difficulty 
in  urinating  or  total  inability.  When  these  cases  are  unrelieved  the 
bladder  becomes  very  much  distended,  and  in  a  day  or  two  febrile  symp- 
toms may  develop. 

Rupture  of  the  membranous  and  prostatic  urethra  when  not  promptly 
relieved  inevitably  leads  to  urinary  extravasation  (see  page  222).  When 
occurring  together  with  fracture  of  the  pelvis  the  prognosis  is  very 
grave. 

Damage  to  the  urethra  in  any  locality  is  a  very  serious  condition  for 
the  reason  that  if  not  properly  treated,  and  perhaps  owing  to  the  irritat- 
ing effects  of  the  urine,  a  most  obstinate,  very  hard,  tough,  and  retractile 
stricture  inevitably  forms. 

Treatment. — In  all  cases  when  the  bulbous,  membranous,  or  pros- 
tatic urethra  is  the  seat  of  damage,  external  urethrotomy  should  be 
promptly  performed.  The  blood-clots  are  to  be  turned  out,  the  parts 
are  freely  irrigated,  and  the  torn  edges  of  the  wound  are  sought  for, 
brought   evenly   together,    and    stitched   with    several    catgut    sutures. 


176  STRICTURE   OF  THE    URETHRA. 

When  the  rupture  has  been  incomplete,  it  is  usually  easy  to  find  the  torn 
ends  of  the  urethra ;  when  it  is  complete,  difficulty  may  be  encountered, 
but  it  must  be  overcome.  It  is  important  in  applying  the  sutures  to 
include  only  the  cavernous  and  muscular  tissues  and  to  spare  the 
mucous  membrane.  A  catheter  is  passed  into  the  bladder  and  there 
retained,  the  wound  on  the  outside  being  left  slightly  open  for  drainage. 
In  a  few  days  the  catheter  may  be  taken  out,  after  which  it  is  necessary 
to  pass  an  olivary  bougie  or  a  sound  every  week  or  oftener.  If  this 
treatment  is  carefully  followed,  the  resulting  damage  will  not  be  very 
great,  and  it  is  fair  to  hope  that  recontraction  ot  the  canal  will  not 
occur. 

In  the  event  of  the  formation  of  a  dense  nodular  retractile  traumatic 
stricture  the  surgeon  can  follow  the  indications  for  operation  as  the 
case  presents ;  he  may  resect  the  morbid  portion  of  the  urethra,  and 
then  approximate  and  suture  the  cut  ends ;  he  may  resect  and  having 
passed  a  catheter  allow  the  wound  to  granulate  and  heal,  or  he  may 
endeavor  to  make  a  splice  in  the  canal  by  means  of  the  transplantation 
of  mucous  membrane. 

When  healing  has  finally  been  produced  it  is  important  that  the 
patient  should  be  made  to  understand  very  clearly  that  for  the  rest  of 
his  life  the  frequent  and  careful  introduction  of  a  sound  is  necessary 
in  order  to  prevent  recontraction  of  the  urethral  canal. 

Pathology  of  Gonorrhceal  Stricture. — A  better  understanding  of 
this  subject  will  be  gained  by  first  reading  the  section  on  the  Pathology 
of  Chronic  Gonorrhoea  (see  page  77  et  seq.). 

Early  in  chronic  urethritis  the  newly-formed  submucous-tissue 
infiltration  is  still  soft  and  succulent,  and  when  it  produces  very 
decided  diminution  of  the  calibre  of  the  urethral  canal  it  may  be  called 
"  soft  stricture."  As  the  morbid  tissue  grows  older,  and  connective- 
tissue  cells  take  the  place  of  the  small  round-cells,  it  becomes  more 
condensed,  and  then  the  stricture  can  no  longer  be  called  soft,  and  the 
term  " semi-fibrous "  maybe  applied  to  it.  Thus  in  the  domain  of 
chronic  anterior  urethritis  we  recognize  in  clinical  practice,  as  ulterior 
results,  the  soft  and  the  semi-fibrous  strictures.  These  rather  succulent 
strictures  as  time  goes  on  may  become  more  condensed,  and  then  what 
is  known  as  modular  stricture  is  produced. 

Figs.  35  and  36  illustrate  two  forms  of  stricture  of  the  urethra.  In 
Fig.  35  is  shown  one  of  the  forms  of  large-calibred  stricture,  while  Fig. 
36  is  from  a  section  of  a  more  extensive  tight  stricture,  contracting  the 
urethra  to  a  considerable  degree.  These  figures  serve  not  only  as  a  text 
for  the  exposition  of  the  detailed  minute  anatomy  of  urethral  stricture, 
but  also  as  a  practical  demonstration  of  the  topographical  distribution 
and  general  structure  of  two  extreme  forms  of  strictures. 


PATHOLOGY  OF  GONORRHCEAL  STRICTURE. 


177 


Both  of  these  strictures  were  evident  to  gross  inspection.  In  Fig.  35 
is  a  section  of  the  stricture  shown  grossly  in  Fig.  52.  This  stricture 
was  situated  in  about  the  middle  of  the  anterior  urethra ;  it  lay  a  little 


Fig.  35. 


Showing  a  section  through  a  superficially-seated  stricture,  with  moderately  dense,  newly-formed 

connective  tissue. 

to  one  side  of  the  roof  of  the  urethra,  and  looked  like  a  bit  of  coarse 
cotton  thread  stretching  across  the  surface  of  the  membrane  for  a  very 
limited  distance — only  three  or  four  millimetres.     The  urethra  was  per- 

Fig.  36. 


Showing  a  section  through  a  firm  inodular  stricture,  the  connective  tissue  being  so  dense  as  to 

resemble  cicatricial  tissue. 

fectly  normal  both  above  and  below  the  tiny  constricting  band  or  thread. 
A  vertical  section  of  the  urethra  passing  transversely  through  this  little 
band  presents  the  appearance  shown  in  Fig.  35. 

This  stricture  is  very  superficial  ;  in   fact,  most  of  it   is   raised   up 

12 


178  STRICTURE   OF  THE   URETHRA. 

above  the  surface  of  the  urethra,  although  a  slight  amount  of  connec- 
tive tissue  stretches  out  in  the  mucosa  on  either  side  of  the  centrally- 
elevated  nodule  which  corresponded  to  the  thread-like  band  shown.  In 
Fig.  35  the  stricture  is  composed  of  fairly  dense  newly-formed  connec- 
tive tissue,  which,  however,  lies  very  superficially  :  the  wall  of  the  ure- 
thra itself  is  but  very  little  invaded  by  the  stricture.  This  is  a  good 
illustration  of  the  least-developed  form  of  stricture.  This  band  or 
ring  form  of  stricture  is  not  common,  and  may  be  said  to  be  in  reality 
rare.  In  this  case  but  one  imperfect  band  was  present,  but  in  very 
exceptional  instances  several  bands  may  be  found.  As  a  general  rule, 
when  bands  of  stricture  exist,  the  whole  expanse  of  mucous  membrane 
on  which  they  appear  is  the  seat  of  morbid  change.  This  first  form  of 
stricture  belongs  to  the  category  of  rather  mild  and  superficial  fibrous 
stricture. 

Fig.  36  shows  a  much  more  extensively  developed  form  of  stricture. 
In  this  instance  the  lumen  of  the  urethra  was  considerably  narrowed — 
approximately  to  about  the  calibre  of  a  No.  9  or  10  sound  (French). 
This  stricture  formed  an  annular  ridge  extending  transversely  about 
one-quarter  way  round  the  urethra  at  the  junction  of  the  membranous 
with  the  bulbous  portions.  In  the  vertical  section  (Fig.  36)  of  the  ure- 
thra passing  through  the  stricture  it  will  be  seen  that  the  stricture  is 
due  to  the  development  of  a  conical  lump  of  newly-formed  connective 
tissue  which  extends  deeply  into  the  wall  of  the  urethra,  so  as  to  involve 
the  membrane  very  extensively,  almost  down  to  the  albuginea.  This 
mass  of  connective  tissue  is  very  dense,  and  forms  a  fairly  rigid  body, 
and  altogether  it  has  the  structure  resembling  cicatricial  tissue.  The 
interlacing  strands  of  dense  fibrillated  fibres  composing  the  mass  pass 
in  several  directions  :  many  of  them  pass  circularly  about  the  urethra, 
while  others  run  up  and  down  the  canal  for  a  short  distance.  Over  the 
centre  of  the  stricture  the  urethral  surface  is  elevated  in  a  conical  point, 
while  on  either  side  the  epithelium  is  somewhat  thickened.  At  the 
right-hand  side  of  the  drawing  the  mucosa  is  thickened,  and  some 
newly-formed  vessels  pass  up  vertically  toward  the  surface,  as  is  gener- 
ally the  case  in  the  skin. 

This  latter  stricture  is  in  striking  contrast  to  the  previous  one  in  its 
lack  of  elasticity,  extensive  involvement  of  the  urethral  wall,  and  corre- 
spondingly greater  degree  of  narrowing  of  the  urethral  canal.  It  is 
merely  necessary  to  say  that  in  this  case  only  a  limited  portion  of  the 
lumen  of  the  urethra  was  involved,  and  it  is  here  portrayed  and  de- 
scribed in  order  that  the  pathological  condition  can  be  placed  in  con- 
trast with  the  healthy  tissues  around  it.  In  cases  in  which  the  process 
is  deeper  and  denser  the  same  pathological  conditions  are  presented.  As 
the  stricture  increases  in  extent  and  depth  the  same  cicatricial  tissue  is 


SYMPTOMS   OF  STRICTURE.  179 

formed,  going  down  as  far  as  the  tunica  albuginea,  and  even  involving 
it  and  surrounding  the  whole  lumen  of  the  urethra. 

This  form  of  stricture  is  known  in  clinical  practice  as  the  modular 
stricture,  which,  when  fully  developed,  involves  a  greater  or  less  seg- 
ment of  the  urethral  canal  in  its  totality. 

Development  and  Course  of  Stricture. — The  opinion  is  very 
generally  held  by  surgeons  that  the  development  and  course  of  stricture 
of  the  urethra  are,  as  a  rule,  quite  rapid.  Many  of  the  laity  also  share 
this  view,  and,  as  a  result,  the  surgeon  is  frequently  asked  or  impor- 
tuned by  men  recovering  from  gonorrhoea  to  pass  a  sound  in  order  to 
prevent  stricture.  Unfortunately,  the  surgeon  often  yields,  and  com- 
monly to  the  sorrow  of  the  patient. 

The  truth  is  that  in  its  development  stricture-formation  may  be  quite 
rapid,  but  that,  as  a  rule,  it  is  moderately  slow,  and  that  in  a  goodly 
proportion  of  cases  five,  ten  to  twenty  years  may  elapse,  and  yet  the 
normal  urethral  calibre  will  only  be  reduced  about  one-third  or  even 
less.  To  the  latter  category  belong  the  very  slow  cases.  It  is  signifi- 
cant of  the  usual  slowly-developing  character  of  stricture  that  the 
greatest  number  of  patients  apply  for  relief  between  the  twenty-fifth 
and  fiftieth  years. 

Symptoms  of  Stricture. — One  of  the  earliest  symptoms  of  stricture 
is  a  slight  mucopurulent  discharge,  which  may  be  observed  only  in  the 
morning,  as  already  described  (see  Chronic  Anterior  Urethritis),  or  it 
may,  in  exceptional  cases,  be  noticed  at  intervals  during  the  day. 
Usually  the  quantity  of  secretion  is  very  scant,  but  exceptionally  a 
good-sized  drop  may  be  expressed  from  the  meatus  once  or  twice  a  day, 
and  perhaps  oftener.  There  is  greater  or  less  pus-formation  in  all  cases 
of  stricture,  but  it  usually  can  only  be  seen  by  examining  the  urine. 
When  stricture  is  uncomplicated  with  bladder  inflammation,  the  urine 
is  usually  clear,  but  contains  more  or  less  threads  and  lumpy  masses. 
In  some  quite  old  cases  there  may  be  some  pus  and  much  flat  epithelium 
in  a  state  of  fatty  degeneration. 

Some  patients  quite  early  or  at  more  remote  periods  after  gonorrhoea 
complain  of  various  subjective  symptoms,  such  as  slight  uneasiness,  a 
mild  smarting,  or  a  decidedly  burning  pain  during  micturition.  In 
some  cases  increased  frequency  of  urination,  with  pain  at  the  beginning 
or  end  of  the  act,  is  experienced,  due  to  coexistent  chronic  posterior 
urethritis.  In  other  cases  there  is  concomitant  urethro-cystitis  even 
quite  early  in  the  development  of  the  stricture. 

As  a  rule,  I  think  that  strictures  in  the  pendulous  urethra  arc  some- 
times attended  with  the  uneasy  smarting  and  mildly  burning  sensation 
in  the  canal  and  at  the  end  of  the  penis,  while  those  in  the  subpubic 
portion  are  sometimes  complicated  with  decidedly  burning,  even  scald- 


180  STRICTURE  OF  THE   URETHRA. 

ing,  pains,  particularly  when  the  posterior  urethra  and  bladder  are  also 
involved. 

Another  striking  symptom  may  be  complained  of  quite  early — 
namely,  a  more  frequent  desire  to  make  water.  Great  variation  in  this 
symptom  is  observed  in  the  general  run  of  cases.  In  some  patients  the 
intervals  between  urination  may  be  three  or  four  hours,  and  in  others 
they  may  be  much  shorter,  the  desire  coming  every  hour  or  even  more 
frequently.  This  great  frequency,  however,  is  commonly  seen  in  old 
cases  complicated  with  cystitis.  At  first  the  desire  is  experienced  during 
the  day,  but  as  the  morbid  condition  increases  the  sufferer  finds  that  he 
has  to  empty  his  bladder  several  times  during  the  night. 

As  the  stenosis  of  the  urethra  increases  the  expulsive  power  of  the 
bladder  is  materially  impaired.  Some  patients  state  that  the  first  inti- 
mation of  a  stricture  known  to  them  was  the  necessity  for  greater  than 
usual  force  in  voiding  their  urine.  This  symptom  may  in  some  cases  be 
noticed  quite  early,  but,  as  a  general  rule,  the  stricture  is  well  advanced 
and  the  urethral  lumen  quite  small  before  it  is  experienced.  In  general, 
the  bladder  gradually  accommodates  itself  to  the  extra  strain  put  upon 
it  by  means  of  the  hypertrophy  of  its  muscular  fibres.  Owing  to  this 
fact,  a  patient,  particularly  an  obtuse  or  an  insensitive  or  careless  one, 
may  not  for  several  years  appreciate  the  fact  that  there  is  an  impediment 
to  his  stream,  and  that  he  uses  more  than  ordinary  expulsive  power.  In 
cases  where  the  stricture  forms  rapidly  this  symptom  may  quite  promptly 
be  appreciated. 

Synchronously  with  the  diminished  explosive  power  of  the  bladder, 
changes  in  the  shape  of  the  stream  of  urine  may  occur,  and  they  usually 
make  an  impression  on  the  patient's  mind.  In  very  many  cases,  though 
other  symptoms  have  existed,  this  is  the  first  one  to  attract  the  patient's 
attention.  The  shape  of  the  stream  depends  largely  on  the  conformation 
of  the  meatus.  If  this  slit  is  wide,  the  urine  may  escape  in  two  small 
streams — one  with  an  upward  tendency,  while  the  lower  one  curves  over 
and  falls  barely  beyond  the  patient's  toes.  Then,  again,  in  cases  of 
large  meatus  a  sputtering,  broken,  and  short,  or  a  flat,  fan-like  stream 
may  be  observed.  When  the  meatus  is  normal  or  quite  small  the  stream 
may  be  thin  and  wiry,  and  perhaps  a  little  twisted.  Then,  again,  it  may 
be  very  much  twisted,  forked,  and  corkscrew-like.  In  some  cases  the 
stream,  though  small,  is  quite  strong  and  is  well  projected,  while  in 
others  it  is  weak,  hesitating,  intermittent,  and  falls  within  a  few  inches 
of  the  patient's  body,  often  wetting  his  clothes.  In  almost  all  well- 
advanced  cases  there  is  more  or  less  dribbling  of  urine  after  micturition, 
owing  to  the  inelasticity  of  the  urethral  walls  and  imperfect  closure  of 
the  canal,  and  the  diminished  contractile  power  of  the  accelerator  urinse 
muscle  and  of  the  involuntary  fibres  of  the  corpus  spongiosum.     This 


SYMPTOMS   OF  STRICTURE.  181 

symptom  may  be  well  marked  in  cases  of  stricture  in  the  deep  urethra, 
and  it  is  usually  very  pronounced  when  the  pendulous  urethra  is  in- 
volved. 

In  more  advanced  cases  patients  may  experience  more  or  less  diffi- 
culty in  starting  the  stream  of  urine.  They  frequently  make  several 
attempts  during  one  or  more  minutes  before  the  urine  appears,  and  then 
it  frequently  stops,  and  renewed  efforts  are  required  to  start  it  again.  As 
the  stenosis  grows  more  compact  and  the  urethral  canal  is  more  and 
more  contracted  all  these  disturbances  in  urination  may  become  more 
severe  and  constant.  The  patient  experiences  a  constant  desire  to  make 
water,  and  the  act  is  attended  with  much  pain.  There  is  often  pain  in 
the  bladder  and  above  the  pubis,  in  the  perineum,  testes,  vas  deferens, 
and  groins.  In  some  cases  patients  complain  of  a  constant  dull  aching 
or  spasmodic  pain  in  the  glans  penis,  which  may  lead  the  surgeon  to 
suspect  stone  in  the  bladder.  The  mucous  membrane  behind  the  strict- 
ure often  becomes  inflamed,  and  then  this  condition  may  attack  the 
ejaculatory  ducts,  the  verumontanum,  and  the  seminal  vesicles,  and  may 
disturb  their  function.  As  a  result,  there  may  be  sexual  inability  or 
frequent  emissions,  pain  on  coitus,  and  ejaculation  may  be  attended  by 
a  severe  stabbing  pain.  In  some  cases  the  semen  passes  backward,  and 
is  later  on  discharged  with  the  urine.  In  such  instances  the  power  of 
fecundation  is  lost. 

In  advanced  cases,  where  great  straining  is  necessary  for  the  expul- 
sion of  the  urine,  prolapse  of  the  rectum,  hemorrhoids,  and  uneasy  and 
painful  sensations  in  the  rectum,  perhaps  with  spasm  of  its  muscles, 
may  result.  In  some  cases  the  contents  of  the  rectum  are  expelled  with 
every  attempt  at  urination.  In  these  cases  we  frequently  see  that  the 
penis  is  more  or  less  congested,  the  blood  remaining,  occasionally  from 
mild  extravasation,  in  the  areolae  of  the  corpora  cavernosa  and  corpus 
spongiosum,  and  giving  them  an  unusually  firm  consistence.  Then, 
again,  painful  erections,  like  chordee,  may  occur,  and,  as  a  result,  there 
may  be  mild  hematuria. 

Epididymitis  and  epididymo-orchitis  of  a  low  form  and  with  slow 
and  not  painful  invasion  may  sometimes  occur  rather  late  in  the  course 
of  stricture.  In  somewhat  exceptional  cases  these  complications  come 
on  rapidly,  with  much  pain. 

In  old  men  with  firm  stricture  hernia  may  be  produced  by  the  great 
efforts  in  straining.  In  these  old  cases  it  is  not  uncommon  to  observe 
a  more  or  less  profuse  mucopurulent  discharge,  either  transparent  or 
opaque. 

Retention  of  urine  is  a  quite  common  complication  of  stricture  of  the 
urethra,  particularly  in  cases  in  which  the  stenosis  is  in  Region  No.  1. 
It  is  observed  less  frequently  when  Regions  Nos.  2  and  3  are  the  seats 


182  STRICTURE   OF  THE    URETHRA. 

of  contraction.  In  some  cases  this  complication  is  the  first  warning 
indication  of  the  presence  of  stricture. 

Some  patients  seem  particularly  susceptible  to  retention  of  urine, 
which  seizes  them  at  shorter  or  longer  intervals  for  years.  Others, 
again,  in  spite  of  many  and  varied  hygienic  and  sexual  transgressions, 
seem  to  be  free  from  this  accident.  In  still  other  cases  during  a  period 
of  twenty-five  or  more  years  retention  may  occur  but  once  or  twice, 
even  though  the  patient  leads  a  free-and-easy  life.  Retention  is,  as  has 
been  stated,  due  to  hyperemia  of  the  mucous  membrane  lining  the 
stricture  and  spasm  of  the  compressor  urethra?  muscle. 

In  some  old  cases  of  very  tight  stricture  the  urine  constantly  drib- 
bles from  the  meatus,  and  patients  thus  afflicted  are  said  to  suffer  from 
incontinence.  In  this  condition  there  is  a  constantly  distended  bladder, 
and  the  external  sphincter  vesicas  and  compressor  urethras  muscle, 
having  lost  much  of  their  tonicity,  possess  but  feeble  contractile  power, 
and  as  a  result  the  urine  dribbles  away.  In  such  cases  the  genitals  and 
thighs  may  become  much  excoriated,  the  under-linen  and  trousers  are 
constantly  soaked,  and  the  patient  carries  with  him  an  offensive  odor  of 
decomposed  urine.  In  this  condition  there  is  usually  sufficient  over- 
flow to  relieve  the  patient  of  the  imperative  desire  to  urinate  which  is 
so  constant  in  retention. 

Complications  occurring  in  the  Course  of  Stricture. — As  a  result 
of  advanced  stricture  the  urethra  posterior  to  it  becomes  more  or  less 
dilated,  and  its  walls  attenuated  in  spots  or  patches  by  the  retarded 
stream  of  urine  forced  forward  by  bladder-contraction.  This  dilatation 
involves  the  membranous  and  prostatic  urethra,  and  it  may  be  so 
extensive  that  the  fore-finger  may  be  readily  admitted  into  the  canal. 
In  some  cases  a  decided  pouch  is  produced.  The  mucosa  and  its  under- 
lying connective-tissue  layer  are  much  thickened,  the  prostatic  and 
ejaculatory  ducts  are  dilated,  and  the  floor  of  the  urethra  is  traversed 
with  longitudinal  and  irregular  septa,  between  which  are  little  pouches 
of  dilatation. 

Superficial  and  deep  ulcerations  very  frequently  occur  behind  old 
strictures.  In  some  cases  large  and  ragged  excavations  are  produced. 
Concretions  are  not  infrequently  found  imbedded  in  the  urethral  mucous 
membrane. 

Abscesses  and  fistula?  sometimes  develop  in  the  neighborhood  of 
strictures.  They  may  begin  in  inflamed  follicles  or  in  small  ulcerated 
spots  which  allow  the  escape  of  a  few  drops  of  urine  into  the  surround- 
ing connective  tissue.  They  then  burrow  in  various  directions,  and 
form  hard,  circumscribed  masses  on  the  external  surface,  which  soften 
and  give  rise  to  fistulas,  of  which  many  may  open  on  the  perineum,  the 
scrotum,  the  nates  and  thighs,  and  upon  the  abdomen  as  high  up  as  the 


PLATE   III. 


COMPLICATIONS   OF    STRICTURE. 
Dilatation  of  urethra  behind  stricture  and  hypertrophy  of  bladder  walls. 


COMPLICATIONS   OF  STRICTURE.  183 

umbilicus.  These  fistula?  usually  have  but  one  opening  into  the  urethra. 
As  they  grow  older  their  walls  become  covered  with  a  layer  of  pave- 
ment epithelium,  which  in  many  cases  must  be  curetted  away  before 
healing  can  be  brought  about.  Calcareous  matter  may  be  deposited  in 
these  fistulse. 

Abscess  of  the  prostate  occurs  in  some  cases  of  very  old  stricture, 
particularly  those  which  have  been  subjected  to  much  instrumentation. 
It  discharges  into  the  urethra,  the  perineum,  or  the  rectum. 

The  muscular  layers  of  the  bladder  become  much  hypertrophied, 
and  at  the  same  time  there  is  great  increase  in  its  connective  tissue.  As 
a  result,  the  walls  of  the  bladder  are  increased  to  five  or  six  times  their 
normal  thickness,  measuring  in  some  cases  a  full  inch.  The  mucous 
membrane  then  presents  prominent  ridges  which  resemble  the  columnse 
carnese  of  the  heart's  cavities.  Between  these  ridges,  owing  to  the 
violent  expulsive  efforts  of  the  bladder,  thinned  spaces  or  sacculi  some- 
times form,  which,  when  the  bladder  is  full,  jut  out  like  pouches  which 
sometimes  become  of  very  large  size,  even  larger  than  the  bladder  itself, 
and  frequently  calculi  form  in  them. 

In  some  cases  the  sac  or  pouch  becomes  thinned,  perhaps  from 
ulceration,  and  the  bladder  being  over-distended  with  urine,  it  gives 
way  at  this  part.  The  urine  escapes  into  the  peritoneal  cavity  or  into 
the  pelvic  connective  tissue  behind  the  triangular  ligament.  When  this 
occurs  the  bladder-tumor  previously  felt,  extending  toward  the  umbili- 
cus, ceases  to  be  salient.  In  these  cases  patients  usually  die  from 
shock,  particularly  when  the  rupture  has  been  into  the  peritoneal 
cavity. 

As  the  bladder  becomes  more  profoundly  affected  certain  changes 
take  place  in  the  urine.  At  first  it  is  of  acid  reaction  and  slightly 
cloudy  from  the  presence  of  pus.  Then,  owing  to  its  partial  retention 
in  the  bladder,  it  becomes  more  turbid,  and  finally,  from  decomposition, 
it  becomes  ammoniacal  and  emits  a  penetrating  fetid  odor.  It  then  has 
a  very  cloudy  appearance  and  contains  much  ropy  mucus.  Under  these 
circumstances  blood,  usually  in  small  quantities,  may  escape  from  the 
urethral  walls,  and,  mingling  with  the  urine,  will  give  it  a  dirty-brown 
color. 

The  morbid  changes  which  are  seen  in  the  urethra  and  bladder  may 
extend  to  the  ureters  and  kidneys.  The  ureters  become  much  dilated 
by  the  backward  pressure  of  the  urine,  so  that  in  postmortem  specimens 
the  forefinger  or  thumb  may  be  passed  into  them,  and  even  greater 
dilatation  than  this  has  been  observed.  The  pelves,  infundibula,  and 
calices  of  the  kidney  may  be  distended,  and  the  seat  of  chronic  inflam- 
mation and  microbic  infection.  With  the  advent  of  advanced  bladder 
symptoms,  particularly  when  the  ureters  and  kidneys  are  affected,  a 


184  STRICTURE  OF  THE    URETHRA. 

marked  condition  of  ill-health  supervenes.  These  patients  become 
sallow,  have  much  digestive  disturbance,  and  rapidly  lose  weight. 
They  become  chronic  invalids,  complain  constantly,  are  anxious  and 
careworn,  and  suffer  from  pain  in  the  back  and  loins.  They  not  infre- 
quently have  symptoms  similar  to  fever  and  ague.  In  an  advanced 
case  every  few  minutes  the  patient  has  a  desire  to  pass  his  urine.  He 
then  strains  violently,  writhes  with  intense  pain  and  agony,  and  breaks 
out  in  a  cold  sweat,  and,  as  a  result,  he  is  perhaps  able  to  expel  only  a 
few  drops  of  putrid,  scalding  urine.  These  sufferings,  which  make  the 
patient  a  pitiable  object,  have  much  to  do  with  hastening  death.  In 
some  cases  mild  or  severe  urethral  fever  follows  every  attempt,  no 
matter  how  gentle,  at  instrumentation  of  the  urethra. 

Pains  at  such  remote  parts  as  the  heel  and  the  sole  of  the  foot  have 
been  complained  of,  as  well  as  neuralgic  affections  of  the  testes,  abdomen, 
and  thighs. 

In  some  very  bad  cases  the  patient  continually  loses  ground,  and 
finally  dies  of  exhaustion.  In  other  cases  a  low  grade  of  urinary  fever, 
with  marked  evidences  of  malnutrition,  tortures  the  patient  until  death 
relieves  him. 

Varieties  of  Stricture. — A  number  of  terms  are  used  in  the  descrip- 
tion of  the  various  forms  of  stricture.  The  thread-like  form  consists  of 
one  or  more  thin  bands,  usually  seated  just  under  the  mucous  mem- 
brane and  not  involving  the  submucosa  deeply.  This  is  also  called  the 
linear  stricture.  The  diaphragmatic  stricture  consists  of  a  thickened 
fold  of  mucous  membrane  with  a  centrally-  or  laterally-placed  iris-like 
opening,  small  or  large.  The  crescentic  or  bridle  stricture  is  that  form 
in  which  the  mucous  fold  juts  from  about  one-half  of  the  lumen  of  the 
canal,  either  laterally  or  on  the  upper  or  lower  wall.  By  the  term 
annular  stricture  a  more  or  less  complete  ring,  narrow  or  broad,  of  the 
stenosed  urethral  canal  is  understood.  When  the  resulting  narrowed 
tube  to  the  extent  of  one  or  more  inches  is  irregular  in  its  course,  the 
case  is  called  one  of  tortuous  stricture. 

The  terms  soft  and  hard  stricture,  as  we  have  already  seen,  are  fre- 
quently used,  with  much  significance,  in  describing  the  degree  of  density 
of  the  urethral  infiltration  present. 

The  So-called  Inflammatory  Stricture. — An  inflamed  or  hyper- 
semic  condition  of  the  mucous  membrane,  usually  of  short  duration, 
sometimes  occurs  at  the  affected  part  in  stricture  of  the  urethra.  In 
such  cases  the  patients  are  said  to  have  inflammatory  strictures.  They 
simply  have  strictures  of  greater  or  less  calibre,  which,  owing  to  various 
causes,  such  as  alcoholic  and  sexual  excesses,  cold,  horseback  and  bicycle 
riding,  laborious  work,  and  bodily  strain,  have  for  a  time  become  im- 
permeable by  reason  of  the  swelling  of  the  mucous  membrane.     Such 


PLATE   IV. 


COMPLICATIONS    OF    STRICTURE, 
showing  false  passages,  perirectal  abscess,  cystitis,  and  ulcers  of  the  biadder. 


EXPLORATION  OF  THE   URETHRA.  185 

accidental  conditions  should  not  be  dignified  by  such  a  formidable  name 
as  inflammatory  stricture. 

In  some  cases  of  stricture,  particularly  when  seated  in  the  subpubic 
curve,  as  a  result  of  the  causes  just  mentioned,  and  sometimes  from  the 
intemperate  use  of  exploratory  instruments,  the  compressor  urethra? 
muscle,  with  perhaps  the  external  vesical  sphincter,  becomes  the  seat 
of  spasm  and  renders  the  urethra  for  a  time  impermeable.  This  condi- 
tion is  paraded  at  great  length  by  some  writers  under  the  title  of  spas- 
modic stricture.  It  is  simply  an  ephemeral  complication,  and  is  in  no 
sense  whatever  a  morbid  entity.  It  is  more  common  in  some  patients 
than  in  others. 

The  So-called  Spasmodic  Stricture. — While  performing  catheter- 
ization upon  irritable  subjects  it  has  occasionally  been  observed  by  nearly 
every  surgeon  that  the  instrument  is  grasped  and  temporarily  held  by 
the  urethral  walls,  even  when  the  canal  is  free  from  permanent  obstruc- 
tion. In  this  case  the  sound  or  catheter  acts  as  a  foreign  body,  and 
the  irritation  which  it  produces  is  followed  by  contraction  of  muscular 
fibres  in  accordance  with  the  familiar  laws  of  reflex  action. 

In  other  cases  the  eccentric  irritation  is  caused  by  laceration,  abra- 
sion, or  a  wound  of  the  lining  membrane,  such  as  may  ensue  from  the 
rough  use  of  a  catheter  or  other  surgical  instrument.  This,  of  itself, 
may  excite  spasm,  or  the  same  may  be  induced  by  contact  of  urine 
with  the  raw  surface. 

Striking  examples  of  urethral  spasm  are  also  met  with  as  the  result 
of  irritation  about  the  rectum  excited  by  the  presence  of  a  tape-worm, 
ascarides,  hemorrhoids,  fissure  of  the  anus,  fecal  accumulation,  or  by 
operations  upon  this  part,  especially  the  ligature  of  piles  and  operations 
on  the  cord  and  testes. 

Among  other  causes  of  spasm  are  the  presence  of  a  stone  in  the 
bladder  or  urethra ;  organic  stricture  of  this  canal ;  long  retention  of 
the  urine ;  digestive  derangements ;  exposure  to  sudden  changes  of 
temperature  ;  and  mental  emotion. 

Instruments  for  the  Exploration  of  the  Urethra. — For  the  diag- 
nosis of  stricture  we  employ,  in  the  main,  bougies  of  various  kinds 
which  are  flexible,  and  sounds  which  are  made  of  solid  metal. 

For  simplicity  and  precision  in  use  these  instruments  are  made  in 
sizes  which  increase  from  small  to  quite  large  ones,  and  are  graduated 
according  to  their  diameters,  which  are  clearly  portrayed  by  certain 
scales  used  for  measurement.  The  most  extensively-used  scale  for 
urethral  instruments  is  the  French  one,  called  the  filiere  Charriere, 
which  progresses  by  steps  of  one-third  of  a  millimetre  in  diameter; 
thus,  No.  1  represents  an  instrument  one-third  of  a  millimetre  in 
diameter,  No.  2,  two-thirds,  and  No.  3,  three-thirds,  or  one  millimetre. 


186 


STRICTURE  OF  THE    URETHRA. 


In  this  manner  the  scale  progresses  up  to  No.  30,  which  has  a  diameter 
of  ten  millimetres,  there  being  a  bougie  for  each  number.  Thus  it  will 
be  seen  that  a  bougie  No.  6  French  scale  has  a  diameter  of  two  millime- 
tres, No.  9  of  three  millimetres,  No.  12  of  four,  No.  18  of  six,  No.  24. 
of  eight,  and  No.  30  of  ten  millimetres.  The  sizes  of  intermediate 
numbers  can  thus  be  readily  computed  (see  Fig.  37). 

The  English   scale  is   used  by  many   surgeons    and    includes   sizes 
between  Nos.  6  and  18. 

Fig.  37. 


FRENCH        SCALE.  \ 

I    S  3  4    5      6       7       8       S        10        II        12        13        14        15  16  17  18  19         2C  31  22 

oooooo  OOOOOOOOOOOOOOOO 

35       24       33      32      31     30     29    28    27    26    25    Z*t        23 

O  OOOOOOOOoooo 

^^_^  v '  C-.T1EMANN  &C0. 

II  21  3  41  51  6 

i ,  I  i  i  1 1  ii  i  I  i i i I  n  1 1  i  i  i  1  1 1  1 1  1 1 i  I  1 1 1  1 1  i  i  I i ii I  i  i  i  I  ii  1 1  ii  1 1  1 1 1 1  1 1  1 1 1  ii  I  1 1 1 1  1 1  1 1  i  i  1 1 1 1 1 1  1 1  i  I  1 1 1 1  i 1 1 


Sounds. — These  instruments  are  made  of  nickel-plated  steel,  and 
their  surface  should  be  so  smooth  that  they  will  readily  glide  over  the 
urethral  walls.  The  best  all-round  instruments  are  those  having  what 
is  known  as  the  short  curve  at  their  distal  portion.  They  should  be 
conical  at  their  point,  which  while  being  very  round  and  smooth,  is  three 
sizes  smaller  than  the  shaft  of  the  instrument.  It  is  very  desirable 
that  the  handle  of  the  sound  should  be  rather  thin,  tolerably  light,  and 
somewhat  wedge-shaped.     Fig.  38  gives  a  very  clear  idea  of  an  exceed- 

Fig.  38. 


Conical  steel  sound. 


inglv  graceful  and  useful  sound,  which  can  be  used  with  much  delicacy 
of  touch.  Sounds  with  heavy,  clumsy  handles,  insufficiently  nickel- 
plated,  dull  of  surface,  and  not  very  smooth  should  be  avoided. 

As  a  rule,  steel  sounds  are  used  in  practice  in  numbers  between  20 
and  30  French.  AVhen  an  instrument  is  needed  smaller  than  20  F.,  it 
is  well  to  use  the  olivary  bougies.  On  the  other  hand,  when  an  instru- 
ment larger  than  20  or  21  F.  is  needed,  it  is  better,  in  general,  to  use 
the  steel  sound. 

A  very  useful  and  desirable  sound  is  that  known  as  Benequ6's.     (See 


EXPLORATION   OF  THE    URETHRA. 


187 


Fig.  39.)  It  has  a  long  double  curve,  corresponding  nearly  to  the  two 
curves  of  the  urethra  when  the  penis  is  not  elevated  against  the  abdo- 
men. It  is  really  of  the  same  shape  that  a  flexible  bougie  assumes  when 
introduced  into  the  bladder  and  left  to  itself.  Within  certain  restrictions 
and  limitations,  to  be  detailed  later,  this  sound  will  be  found  of  much 


Fig. 


Beneque's  sound. 

service  in  a  number  of  cases.  It  is  only  necessary  to  have  about  six 
of  Beneque's  sounds,  beginning  with  23  F.,  and  ending  with  30  or  32  F. 

Straight  steel  sounds,  of  the  sizes  from  20  to  30  F.,  are  sometimes 
very  useful  in  cases  of  stricture  in  the  pendulous  urethra.  (See  p.  196, 
et  seq.) 

Olivary  Bougies. — These  bougies  are  so  useful  that  the  surgeon  should 
always  have  a  goodly  supply  at  hand.  Formerly  French  bougies  were 
the  best  in  use,  but  of  late  years  excellent  ones  have  been  manufactured 
in  this  country.  The  olivary  bougie  is  the  one  best  fitted  for  general 
purposes,  and  the  blunt  ones  are  seldom  used.     In  Fig.  40  is  well  shown 

Fig.  40. 


Flexible  olivary  bougie. 

an  ideal  olivary  bougie.  The  surgeon  should  exercise  great  care  in  the 
selection  of  these  instruments,  and  should  reject  those  that  are  in  any  way 
faulty.  The  following  are  the  particular  points  of  excellence  necessary 
in  these  bougies  :  The  whole  instrument  should  have  a  smooth,  shining 
surface,  either  black  or  yellow,  and  there  should  be  no  cracks  whatever 
on  it.  The  olivary  point  should  be  rounded  and  smooth,  and  should 
taper  oif  gracefully  into  the  neck,  which  should  very  gradually  increase 
in  size  until  the  shaft  is  reached,  as  is  well  shown  in  Fig.  40.  The  neck 
should  be  very  supple,  and  the  whole  instrument  should  be  so  flexible 
that  on  introduction  it  will  easily  and  almost  imperceptibly  follow  the 
course  of  the  urethra  without  any  discomfort  to  the  patient.  As  a  rule, 
the  olivary  end  should  be  about  seven  sizes  smaller  than  the  shaft  of  the 
bougie,  and  the  neck  at  the  base  of  the  olive  point  should  have  a  diam- 


188  STRICTURE  OF  THE    URETHRA. 

eter  of  about  one-half  of  that  of  the  olivary  expansion.  When  these 
requirements  are  fulfilled  the  instrument  is  quite  gradually  tapering, 
and  will  produce  much  benefit  in  the  process  of  dilatation  of  the  ure- 
thra. All  bougies  with  imperfect  olivary  ends  should  be  rejected.  These 
seemingly  minor  points  are  worthy  of  much  attention. 

The  surgeon  should  provide  himself  liberally  with  these  instruments, 
having  three  or  four  at  least  of  each  size.  The  most  useful  sizes  begin 
at  No.  6  F.  and  end  about  No.  22  or  24  F.  It  will  be  found,  as  a  rule, 
that  bougies  of  sizes  above  No.  22  or  24  French  are  liable,  even  when 
great  care  is  used  in  their  introduction,  owing  to  their  quite  large  calibre 
and  their  comparatively  thin  and  compressible  walls,  to  become  cracked 
or  more  or  less  broken  from  two  to  four  inches  from  their  distal  portion. 
As  a  rule,  therefore,  these'  instruments  may  be  used  for  dilatation  or 
exploration  in  sizes  as  high  as  20  to  24  French.  Beyond  these  limits 
much  better  results  will  be  obtained  from  the  use  of  steel  sounds. 

These  bougies  should  be  kept  (few  in  number)  in  compartments  in 
which,  in  hot  weather,  powdered  French  chalk  may  be  placed  to  pre- 
vent the  gumming  of  opposing  surfaces. 

Filiform  Bougies. — Very  attenuated,  delicate  bougies,  called  fili- 
forms,  are  of  great  service  in  the  diagnosis  and  treatment  of  tight 
strictures.  The  two  principal  forms  are  the  gum  elastic  and  the  whale- 
bone bougies.  French  filiform  bougies  are  very  soft  and  flexible,  and 
are  of  much  use  in  cases  where  the  stricture  does  not  hug  tightly.  In 
examining  tight  strictures  they  soon  become  twisted  and  cracked,  and 
then  it  is  necessary  to  discard  them.     (See  Fig.  41.) 

For  general  use  whalebone  filiform  bougies  are  most  serviceable. 
These  little  exploratory  instruments  have,  as  a  rule,  a  diameter  of  two- 
thirds  of  one  millimetre,  but  some  of  them  are  of  larger  calibre.  Of 
whalebone  filiform  bougies  there  are  two  kinds,  the  short  and  the  long. 
The  short  bougies  are  about  twelve  inches  long,  while  the  long  ones  are 
twenty  to  twenty-five  inches  long.  The  short  instruments  are  employed 
for  purposes  of  diagnosis,  wThile  the  long  ones  are  used  as  conductors  for 
sounds  or  catheters  through  strictured  tissues. 

The  shafts  of  these  instruments  should  be  perfectly  smooth,  and  they 
should  never  be  used  until  they  have  been  carefully  examined,  for  they, 
by  use,  are  apt  to  chip  and  crack  or  become  frayed.  Their  points  are 
usually  tapering,  and  they  end  in  a  minute  bulb.  These  bougies  may 
be  straight  or  they  may  have  eccentric  and  twisted  points.  By  soaking 
them  in  hot  water  they  can  be  twisted  into  any  desired  shape,  spiral, 
zigzag,  and  bent  at  any  angle.  After  soaking  in  hot  water  and  bending 
them  the  shape  may  be  made  stable  by  plunging  them  into  cold  water. 

Whalebone  filiform  bougies  should  be  kept  in  tin  cases  to  ensure 
them  from  the  attacks  of  certain  grubs  or  worms  which  destroy  them. 


EXPLORATION  OF  THE    URETHRA.  189 

As  they  grow  old  they  may  become  brittle,  consequently  it  is  well  to  oil 
them  occasionally. 

Whalebone    bougies   with   tapering  filiform   ends,   increasing  quite 
abruptly  up  to  goodly-sized  10  to  13  F.  shafts,  are  sometimes  of  very 

Fig.  41. 


\ 


Whalebone  filiform  bougies. 


great  service  in  preparing  the  way  for  gradual  dilatation,  for  a  small 
retention  catheter,  or  for  the  introduction  of  a  staff  for  internal  or 
external  urethrotomy.  These  bougies  are  known  as  Banks's  whalebone 
bougies.     (See  Fig.  42). 


Fig.  42. 


Banks's  whalebone  bougies. 

What  are  known  as  Harrison's  dilators  or  whips  are  often  very  use- 
ful for  quite  rapid  dilatation  at  one  seance.  These  bougies  are  twenty- 
four  inches  long,  and  are  straight  for  thirteen  or  fourteen  inches,  then 
they  taper  down  gradually  to  the  tip.  They  range  in  sizes  between  10 
and  20  French,  and  are  very  soft  and  supple.  Six  of  them  form  a  set, 
the  smallest  of  which  is  filiform  at  its  tip. 

The  French  and  English  filiform  bougies  are  generally  armed  with 
screw  tips,  which  permit  of  their  adjustment  to  catheters  and  to  the 
staffs  of  urethrotomes,  to  which  they  serve  as  guides  to  the  bladder. 
These  bougies  with  screw  tips  are  particularly  frail  at  their  point  of 
junction,  and  as  a  result  can  scarcely  ever  be  used  more  than  once  or 
twice.  The  English  bougies  are  rather  more  brittle  than  the  French 
ones,  but  when  used  carefully,  owing  to  their  stability,  they  traverse 
strictures  with  more  uniform  success  than  the  French  ones  do. 

Bougies  a  Boule. — The  acorn-pointed  bougies,  or  bougies  <%  boule, 
have  already  been  spoken  of.      (See  p.  86,  Fig.  23).      These  instru- 


190  STRICTURE   OF  THE   URETHRA. 

merits  are  indispensable  for  the  diagnosis  of  stricture,  since  they  allow 
us  to  clearly  detect  and  define  hyperplastic  and  inflamed  points  and 
strictures  in  the  anterior  urethra.  The  soft,  flexible  bougies  a  boule 
should  be  the  instruments  of  choice. 

The  Urethrameter. — Since  the  meatus  is  usually  the  narrowest 
part  of  the  urethra  and  varies  very  much  in  its  calibre,  it  may  not 
allow  the  introduction  of  any  of  the  instruments  thus  far  mentioned 
of  sufficient  size  to  thoroughly  explore  the  canal  and  especially  to  detect 
contractions.  An  instrument  which  could  be  inserted  through  a  narrow 
meatus  and  then  be  dilated  within  the  urethra,  with  an  index  at  its 
distal  extremity  showing  the  amount  of  its  dilatation,  was  therefore  a 
desideratum.  This  want  has  been  supplied  by  the  ingeniously  contrived 
urethrameter  of  Dr.  Otis  (Fig.  43). 

Fig.  43. 


Otis's  urethrameter 

For  cases  in  which  the  meatus  is  rather  small  this  instrument  may  be 
of  much  service,  provided  its  bulb  is  not  screwed  up  beyond  30,  or  at  most 
31  F.     Within  these  sharp  limitations  the  instrument  may  be  employed. 

Instruments  for  Operation  upon  the  Urethra. — For  strictures  near 
the  meatus,  the  ordinary  straight  blunt  bistoury  will  answer  every  pur- 
pose to  the  surgeon's  satisfaction. 

One  of  the  most  useful  and  simple  instruments  for  tight  strictures  in 
the  pendulous  urethra  is  Fluhrer's  modification  of  Maisonneuve's  ure- 
throtome. (See  Fig.  44.)  This  consists  of  a  staff  or  conductor  nine  and 
a  half  inches  long,  of  a  calibre  of  12  F.,  grooved  on  its  upper  surface  and 
slightly  curved  at  its  distal  end,  which  is  tunnelled  for  one-eighth  of  an 
inch.     The  triangular  blade  with  a  blunt  apex  is  seated  at  the  end  of  the 

Fig.  44. 


G.TIEMANN  &C0 


Maisonneuve-Fluhrer  urethrotome. 

stylet,  and  is  provided  with  a  handle.  The  whalebone  guide  having  been 
passed  down  the  urethra  and  into  the  bladder  if  possible,  the  grooved 
staff  is  slid  over  it  as  far  as  the  penoscrotal  angle,  and  then  the  knife  is 
slowly  and  firmly  pushed  down,  the  penis  being  held  straight  and  tense. 
By  this  urethrotome  the  urethra  may  be  incised  to  18  or  24  F. 

For  the  moderate  or  limited  incision  of  bands  or  broader  coarctations 


EXAMINATION  IN  STRICTURE.  191 

*j£  the  pendulous  urethra,  which  will  admit  of  instruments  as  large  as 
16  or  17  F.,  Civiale's  urethrotome  will  sometimes  prove  very  useful. 
This  instrument  has  a  terminal  bulb  in  which  the  blade  is  concealed, 
but  which  can  be  readily  drawn  out  by  pressing  on  a  spring  near  the 
handle.     A  glance  at  Fig.  45  will  reveal  its  construction. 

Fig.  45. 


Civiale's  urethrotome. 


When  used  with  great  caution  in  a  restricted  number  of  very  care- 
fully selected  cases,  Otis's  dilating  urethrotome  may  be  of  service,  par- 
ticularly when  there  is  a  bona-fide  stricture  of  a  calibre  of  from  16  to 
20  F.  in  the  pendulous  urethra.    (See  Fig.  46). 

For  certain  cases  of  tight  stricture  in  the  urethra  at  the  penoscrotal 
angle,  and  as  far  back  as  the  bulbomembranous  junction,  Maisonneuve's 
urethrotome  is  sometimes  very  serviceable.  This  instrument  is  far  supe- 
rior to  all  other  curved  urethrotomes.  Its  use,  however,  is  restricted  to 
a  certain  class  of  cases.     (See  Fig.  47). 

The  manner  of  using  this  instrument  is  very  simple.  In  most  cases 
the  filiform  flexible  conductor  is  first  introduced  as  a  guide,  and  the 
shaft  of  the  instrument  is  then  screwed  upon  it  and  made  to  follow  it 
into  the  bladder.  In  many  instances  it  is  possible  to  introduce  the 
shaft  alone,  armed  with  the  blunt  point  which  is  always  provided,  when 
it  is  impossible  to  pass  the  conducting  bougie.  In  either  case,  when  the 
bladder  is  fairly  entered,  as  may  be  recognized  by  the  finger  in  the  rec- 
tum, the  penis  is  to  be  put  upon  the  stretch,  and  the  blade  is  carefully 
and  gently,  but  firmly,  thrust  down  to  the  extremity  of  the  groove, 
dividing  every  obstruction  before  it.  It  is  important  to  take  care  in 
withdrawing  the  blade  lest  it  should  cut  healthy  tissue.  To  this  end  the 
penis  must  be  held  tense,  just  as  it  was  when  the  knife  was  pushed  down 
(and  the  transverse  folds  were  effaced).  Then  the  instrument  should  be 
slowly  drawn  out,  care  being  taken  to  keep  exactly  in  the  median  line, 
which  was  traversed  in  the  urethrotomy. 

Preliminary  Considerations  in  the  Examination  of  Cases  of 
Strictures. — Every  case  of  stricture  of  the  urethra  presents  features 
peculiar  to  itself,  consequently  each  case  should  be  carefully  studied  in 
all  its  details. 

The  first  consideration  is  the  age  of  the  patient.  If  he  is  under 
thirty  years  of  age,  in  the  majority  of  cases  the  stricture  will  be 
found  to  be  of  the  soft  or  semi-fibrous  variety.     In  some  cases — rare, 


192 


STRICTURE   OF  THE+URETHRA. 


however,  particularly  when  gonorrhceal  infection  has  occurred  long 
before  puberty — the  subject  may  suffer  from  true  modular  stricture  in 
early  manhood.  Beyond  the  age  of  thirty  we  find  that  strictures  become 
more  condensed  and  fibrous,  while  after  forty,  and  particularly  about  the 
fiftieth  year,  the  modular  or  hard,  fibrous  stricture  is  quite  common. 

Fig.  47. 


Fig.  46. 


A 


Otis's  dilating  urethrotome. 


Maisormeuve's  urethrotome. 


Severe  modular  stricture  may  be  found  in  patients  even  as  early  as  the 
thirtieth  or  thirty-fifth  year. 

The  second  point  for  consideration  is  the  date  of  gonorrhceal  infec- 
tion. We  must  ascertain  the  age  at  which  the  disease  was  acquired  and 
the  facts  as  to  the  severity  and  length  of  the  attack.     Then  the  matter 


INSTR  U  MENTAL  EX  A  MINA  TION.  1 93 

of  relapses  and  later  infections  should  be  taken  up,  and  the  facts  con- 
cerning them  brought  out.  The  inquiry  is  still  incomplete  until  all 
facts  as  to  the  condition  of  the  posterior  urethra,  the  prostate,  and  the 
seminal  vesicles  are  ascertained,  together  with  full  particulars  as  to  the 
condition  of  the  bladder  and  its  functions.  The  condition  of  the  urine 
must  be  clearly  ascertained  as  to  the  presence  of  threads,  pus,  blood,  and 
the  tissue-elements  of  the  kidney. 

As  a  rule,  we  do  not  find  secondary  kidney  complications  in  cases  of 
stricture  until  after  the  fortieth  year.  These  complications  are  preceded 
by  cystitis  of  varying  grades,  which  may  exist  several  or  many  years 
before  the  infective  inflammatory  process  invades  and  creeps  up  the 
ureters  and  involves  the  pelvis  and  parenchyma  of  the  kidneys.  In  all 
cases,  and  particularly  in  subjects  over  forty  or  fifty  years  of  age,  the 
condition  of  the  bladder  and  kidneys  is  a  very  vital  question  in  the 
matter  of  treatment  of  stricture  of  the  urethra. 

It  is  further  necessary  to  take  into  consideration  the  general  health 
of  the  patient,  his  habits,  his  temperament,  his  occupation,  and  his  mode 
of  life. 

Coming  down,  now,  to  a  consideration  of  the  stricture  itself,  it  is 
necessary  to  inform  ourselves  as  to  its  symptoms,  and  particularly  as  to 
how  much  it  interferes  with  urination.  Then  the  frequency  of  the 
urinary  act  is  to  be  considered.  If  there  are  any  complications,  such  as 
fistulse  or  rectal  disorders,  these  must  be  borne  in  mind  in  forming  an 
estimate  of  the  case.  As  to  the  stricture  itself,  it  is  necessary  to  deter- 
mine its  location  and  its  degree  of  contraction,  together  with  the  amount 
in  length  of  the  urethral  canal  which  is  damaged. 

If  the  patient  had  at  an  earlier  date  been  operated  upon  for  stricture, 
all  the  facts  relating  to  this  operation  and  its  results  should  be  gathered, 
and  due  weight  should  be  attached  to  them.  Further  than  this,  the 
length  of  time  in  which  the  stricture  underwent  recontraction  is  an  im- 
portant point. 

Methods  of  Instrumental  Examination. — It  is  a  good  rule  to  have 
the  patient  pass  his  water  in  the  presence  of  the  surgeon  before  he  sub- 
mits to  examination.  In  the  examination  of  the  urethra  for  stricture  it 
is  always  best,  at  first,  to  use  an  olivary  bougie  of  about  20  or  22  F., 
which,  after  lubrication  with  pure  white  vaseline  or  lubrichondrint 
should  be  slowly  introduced  into  the  canal  and  passed  downward  until 
an  obstruction  is  met.  To  my  mind,  this  instrument,  thus  introduced, 
gives  a  better  idea  of  the  state  of  the  canal  as  far  as  the  stricture  than 
any  other,  and  this  is  the  first  condition  to  ascertain.  When  the  strict- 
ure is  not  very  tight,  the  olive  point  of  the  bougie  may  enter  it  as  far  as 
its  expansion.  Then  on  its  withdrawal  a  small  bougie  it  boule,  9  to  10 
French  or  larger  if  indicated,  may  be  carefully  introduced,  and  if  it 

13 


194  STRICTURE  OF  THE   URETHRA. 

traverses  the  stricture  without  impediment,  on  its  return  the  shoulder 
of  the  bulb  will  give  very  important  information  as  to  the  amount  of 
urethra  which  is  the  seat  of  coarctation,  and  to  the  condition  as  to  firm- 
ness or  succulence  of  the  stricture-tissue.  In  practice,  the  bougie  a 
boule,  as  a  general  rule,  will  give  no  precise  information  and  will  not 
adapt  itself  to  ready  use  in  sizes  under  9  or  10  F.  It  may  be  difficult 
in  many  instances  to  introduce  these  small  sizes.  When  strictures  will 
admit  larger  sizes  of  this  form  of  bougie  than  from  12  French  upward, 
their  use  is  generally  productive  of  much  important  information. 

When  it  is  necessary  to  use  large  bulbous  bougies,  the  meatus  may 
sometimes  be  too  small  to  admit  them.  If  expedient  in  these  cases,  the 
meatus  should  be  properly  incised,  but  if  for  any  reason  meatotomy  is  at 
the  time  inadvisable,  the  urethrameter  may  be  employed.  With  this 
instrument  it  is  only  necessary  to  determine  the  lessened  calibre  of  the 
canal  at  the  stricture,  taking  30  or  32  F.  as  the  standard  and  the  maxi- 
mum. There  is  no  need  of  making  measurements  of  the  canal  up  to  35 
or  40  F.,  since  that  amount  of  distention  is  utterly  unnatural,  and  oper- 
ations based  on  that  assumed  calibre  are,  as  a  general  rule,  productive 
of  infinite  harm  to  the  patient.  By  means,  therefore,  of  the  olivary 
bougie,  the  bougie  a  boule,  and  exceptionally  of  the  urethrameter,  we  can 
generally  obtain  scientific  knowledge  of  the  nature  and  extent  of  strict- 
ures of  the  urethra  from  9  to  10  French  upward. 

Much  useful  information  may  be  gained  by  careful  palpation  of  the 
pendulous  urethra,  and  of  the  canal  nearly  up  to  the  bulb,  by  means 
of  the  finger-tips.  This  procedure  will  reveal  little  masses  or  rings 
of  indurated  tissue,  and  also  localized  spots  where  there  is  less  than 
normal  elasticity  if  they  are  present. 

When  the  stenosis  has  reduced  the  canal  to  a  calibre  under  9 
French,  exploration  should  be  made  by  means  of  correspondingly  small 
olivary  bougies  or  of  filiform  bougies. 

Urethral  examinations  for  stricture  should  be  conducted  with  the 
utmost  care,  deliberation,  gentleness,  and  good  judgment.  Our  aim 
should  be  to  cause  the  patient  a  minimum  of  uneasiness  or  pain,  and 
not  to  distend  the  tissues  any  more  than  is  absolutely  necessary. 

It  is  always  an  excellent  rule  to  begin  examinations  with  instru- 
ments of  goodly  size,  and  to  use  smaller  and  smaller  ones  as  the  condi- 
tion of  affairs  indicates. 

In  strictures  of  calibre  above  12  or  15  French  there  is  usually  no 
difficulty  experienced  in  their  exploration,  and  no  preparatory  treatment 
is,  as  a  rule,  necessary.  In  cases  of  tighter  strictures  more  or  less 
difficulty  may  be  encountered. 

In  passing  delicate  olivary  bougies  and  filiforms  into  the  urethra 
much  care  and  patience  is  required.     The  instrument  should  be  well 


INSTRUMENTAL  EXAMINATION.  195 

lubricated,  and  then  held  between  the  finger  and  thumb  in  a  delicate, 
easy  manner.  Steadying  the  penis  with  the  left  hand  and  everting  the 
lips  of  the  meatus  with  the  thumb  and  fore-finger  of  the  same  hand,  the 
operator  passes  the  bougie,  held  with  the  right  hand,  gently  into  the 
urethra.  As  the  mucous  crypts  and  follicles  are  seated  mostly  on  the 
upper  wall,  the  instrument  is  pushed  gently  forward  on  the  lower  wall, 
and  if  it  catches  in  a  follicle  it  should  be  withdrawn  slightly  and  then 
pushed  or  coaxed  along  again.  In  this  way  we,  as  a  rule,  avoid  the 
lacuna  magna  and  other  valve-like  pockets  and  the  orifices  of  ducts  of 
glands.  When  the  instrument  is  down  on  the  face  of  the  stricture,  the 
penis  should  be  mildly  put  on  the  stretch  and  held  at  right  angles  to 
the  body.  Then  the  very  slight  forward  and  backward  movement  of 
the  bougie  may  be  begun,  with  the  idea  of  getting  into  the  mouth  of  the 
stricture.  Sometimes  when  the  penis  is  held  in  the  horizontal  position 
in  conformity  with  the  thighs,  the  bougie  will  slip  in  easily,  whereas 
before  that  it  did  not  pass. 

In  many  cases  the  prompt  introduction  of  a  small  olivary  bougie  or 
a  filiform  may  be  brought  about  by  injecting  into  the  urethra  and  there 
retaining  about  two  drachms  of  pure  olive  oil  or  liquid  vaseline.  This 
injection  distends  and  lubricates  the  canal,  and  often  allows  a  filiform 
bougie  to  slip  through  the  obstruction,  which  before  seemed  impassable. 

It  is  always  necessary  to  bear  in  mind  the  fact  that  the  mouth  of 
the  stricture  may  be  eccentric  rather  than,  as  the  rule,  centric.  There- 
fore, it  is  well,  after  having  failed  with  the  ordinary  straight  filiforms, 
to  try  those  which  have  various  twists  and  curves  at  their  ends,  since 
by  these  we  may  most  unexpectedly  succeed  when  we  had  alreadv 
perhaps  given  up  hope  of  passing  the  stricture. 

It  is  alwrays  wrell  to  have  several  Banks  filiforms  at  hand,  since 
they  often  prove  very  useful  at  unexpected  contingencies. 

In  cases  where  much  difficulty  has  been  experienced,  but  where  the 
passage  of  a  filiform  has  been  accomplished,  this  instrument  may  be 
tied  in  for  several  hours,  and  then  a  Banks  filiform  may  be  introduced, 
and  by  means  of  it  such  temporary  dilatation  may  be  accomplished  that 
the  subsequent  treatment  of  the  case  is  rendered  materially  less  difficult 
and  trying. 

In  some  troublesome  cases  it  is  well  to  pass  several  (as  many  perhaps 
as  six)  filiforms  as  far  down  as  the  stricture,  and  then  to  inject  the 
urethra  with  oil,  after  which  the  surgeon  should  try  to  pass  each  bougie 
individually.  In  this  way  he  may  often  succeed,  whereas  before  adopt- 
ing this  expedient  he  had  failed  utterly.  In  some  very  troublesome 
cases  I  have  succeeded  in  getting  through  a  stricture  by  first  passing 
down  to  its  face  several  filiforms,  and  then  by  means  of  a  hard-rubber 
uterine  syringe,  introduced  as  far  down  as  possible,  injecting  about  two 


196 


STRICTURE   OF  THE   URETHRA. 


drachms  of  very  warm  olive  oil,  and  holding  it  in  the  canal  well  down 
by  means  of  compression  by  the  fingers.  In  this  distended  and  lubri- 
cated condition  of  the  urethral  canal  the  orifice  of  the  stricture  is  often 
so  much  dilated  that  it  will  allow  the  filiform  to  pass  through. 

There  is  another  method  of  procedure  which  should  never  be  for- 
gotten. This,  in  the  main,  consists  in  the  employment  of  a  truncated 
catheter.  A  silver  catheter  (20  or  22  F.)  is  cut  off  at  right  angles  to  its 
shaft  at  the  length  of  six  inches.  The  cut  end  is  then  rendered  round, 
smooth,  and  harmless  by  means  of  a  thin  ring  of  solder,  which  is  evenly 
moulded  around  the  distal  end  of  its  lumen.  This  catheter  then 
becomes  a  very  useful  conductor.  It  is  well  oiled  and  passed  down  to 
the  face  of  the  stricture,  and  there  held  gently  but  quite  firmly ;  then 
through  it  filiforms  are  passed  and  gently  manipulated.  In  many  cases, 
even  when  success  is  not  hoped  for,  this  procedure  will  result  in  the 
passage  of  the  bougie. 

Having  succeeded  in  passing  the  filiform  into  the  bladder,  the  sur- 


Fig.  47. 


Tunnelled  sound  (and  guide). 

geon  can  moderately  dilate  the  canal  by  sliding  over  it  one  or  more 
increasing  sizes  of  the  tunnelled  sound.  (See  Fig.  48.)  By  this  pro- 
cedure (assuming  that  urethrotomy  is  not  contemplated)  the  surgeon  gener- 
ally places  the  urethra  in  such  a  condition  that  it  will  be  passable  by  instru- 
ments for  a  day  or  two  at  least.  If,  however,  the  operation  of  internal 
or  external  urethrotomy  is  indicated,  and  the  time  and  conditions  are 
favorable  to  its  performance,  the  surgeon  then  has  a  clear  field. 

If,  after  prolonged  efforts  to  reach  the  bladder,  much  uneasiness  is 
produced  and  much  hemorrhage  occurs,  and  the  instrument  still  does 
not  pass,  it  is  well  to  stop  the  examination  and  wait  for  a  day  or  two. 

In  some  cases,  after  one  or  more  failures  in  introducing  very  small 
instruments  through  a  stricture,  it  may  be  necessary  to  put  the  patient 
to  bed,  to  allow  him  a  very  spare  diet  (bread  and  milk  preferably),  and 
to  purge  him  well,  in  order  to  relieve  the  pelvic  organs  of  congestion. 
As  a  result,  strictures  previously  impassable  will  often  allow  the  instru- 
ment to  glide  into  the  bladder.     In  many  cases  rest,  an  opium  sup- 


INTRODUCTION   OF  THE  CATHETER.  197 

pository,  and  a  hot  bath  will  relieve  the  stricture  of  congestion,  so  as  to 
allow  the  passage  of  the  exploratory  instrument. 

For  various  reasons,  more  or  less  urgent,  it  is  often  necessary  to  pass 
sounds  and  catheters  through  the  urethra  into  the  bladder. 

Introduction  of  the  Catheter  or  Sound.— A  catheter  or  sound 
may  be  introduced  while  the  patient  is  in  the  standing l  or  sitting  pos- 
ture, but  the  recumbent  position  is  on  many  accounts  the  best,  the 
patient  lying  square  on  the  back,  with  the  shoulders  elevated,  the  knees 
drawn  up  and  somewhat  separated,  the  genital  organs  entirely  exposed, 
and  the  surgeon  standing  on  his  left.  The  operator  now  raises  the  penis, 
which  has  been  carefully  washed,  to  an  angle  of  about  sixty  degrees  with 
the  body,  thereby  effacing  the  anterior  curve  of  the  urethra,  by  means 
of  the  ring  and  middle  finger  of  the  left  hand,  its  palm  looking  upward  ; 
the  thumb  and  forefinger  are  thus  left  free  to  retract  the  prepuce  and 
separate  the  lips  of  the  meatus.  The  catheter  or  sound  previously 
warmed  and  lubricated,  is  held  lightly  between  the  thumb  and  fore  and 
middle  fingers  of  the  right  hand  "  like  a  pen,"  its  shaft  corresponding  to 
the  fold  between  the  abdomen  and  the  left  thigh.  The  introduction  of 
the  instrument  should  be  slow  and  with  the  exercise  of  little  force  ;  its 
own  weight  is  almost  sufficient  to  effect  its  passage  if  properly  directed ; 
if  any  obstruction  be  met  with,  the  instrument  should  be  withdrawn  for 
a  short  distance  and  again  advanced  with  the  direction  of  its  point 
slightly  varied.  While  passing  through  the  first  two  inches  of  the 
urethra  the  point  of  the  instrument  is  inclined  to  the  lower  surface  in 
order  to  avoid  the  lacuna  magna,  and  it  is  well  to  hug  the  lower  wall 
until  the  end  of  the  instrument  has  passed  the  penoscrotal  angle ; 
beyond  this  it  should  be  directed  rather  to  the  upper  surface  to  escape 
the  sinus  of  the  bulb  ;  when  it  has  penetrated  beneath  the  pubes,  the 
shaft  is  brought  round  to  the  median  line  of  the  body  and  parallel  to 
the  surface  of  the  abdomen ;  the  handle  is  now  to  be  elevated  to  a  per- 
pendicular, and  pressure  being  made  with  the  disengaged  hand  upon  the 
mons  Veneris  and  the  root  of  the  penis  for  the  purpose  of  stretching 
the  suspensory  ligament,  be  gently  depressed  between  the  thighs,  not 
forgetting   meanwhile   to    maintain    a    certain    amount    of   progressive 

1  A  method  of  passing  the  sound  known  as  the  tour  de  maitre  is  much  preferred  by 
some  surgeons.  It  is  a  very  simple,  easy,  and  expeditious  procedure  in  the  hands  of  men 
of  large  experience,  but  to  the  beginner  it  may  prove  a  stumbling-block  which  will  bring 
mortification  to  him  and  pain  and  discomfort  to  his  patient.  The  surgeon  sits,  and  the 
patient  stands  before  him.  The  sound  is  introduced  with  its  convexity  facing  the  pubes 
as  far  down  as  the  bulb ;  then  the  shaft  is  quite  rapidly  rotated  toward  the  abdomen, 
when  the  point  readily  slips  into  the  membranous  urethra  and  the  handle  is  depressed 
between  the  thighs.  When  skilfully  done,  this  operation  is  unattended  with  any  un- 
pleasant symptoms  whatever  to  patients,  many  of  whom  prefer  it  on  account  of  its  ease 
and  celerity. 


198 


STRICTURE   OF  THE    URETHRA. 


motion  in  the  instrument,  when  the  point  will  usually  glide  into  the 
bladder.  If  any  difficulty  is  met  with  at  this  stage  of  the  proceeding, 
it  is  probably  because  the  point  has  caught  in  the  extensible  tissue  of 
the  bulb,  and  the  instrument  should  again  be  raised  to  a  perpendicular 


Fig.  49. 


First  step  in  introducing  a  catheter. 

and  slightly  withdrawn,  and  the  penis  elongated  by  traction  before  the 
manoeuvre  is  repeated.  Further  assistance  may  be  obtained,  if  neces- 
sary, during  the  latter  part  of  the  introduction  by  gently  pressing 
against  the  convexity  of  the  instrument  just  back  of  the  scrotum  or  by 
introducing  a  finger  into  the  rectum,  ascertaining  the  exact  position  of 
the  point,  and  guiding  it  forward  and  upward  against  the  posterior  sur- 
face of  the  symphysis ;  the  passage  of  the  extremity  over  the  veru- 
montanum  and  uvula  vesica?  is  often  indicated  by  nausea  or  a  slight 
Tremor  on  the  part  of  the  patient,  and  its  entrance  into  the  bladder  by 
the  flow  of  urine. 

When   dexterously  and  gently  performed,   the   introduction   of  the 
sound  or  catheter  is  accomplished  without  a  hitch  or  halt  in  most  cases. 


TREATMENT  OF  ANTERIOR  STRICTURES. 


199 


By  want  of  gentleness  and  by  bungling  procedures  spasmodic  contrac- 
tion of  the  involuntary  muscle-fibres  of  the  pendulous  urethra  may  be 
induced,  and  also  spasm  of  the  compressor  urethrse  muscle.  In  this 
event  it  is  well  to  desist  or  to  press  the  tip  of  the  instrument  gently  and 
continuously  against  the  obstruction  until  spasm  ceases,  and  then  it  will 
slowly  glide  onward. 

Fig.  50. 


Second  step  in  introducing  the  catheter. 

Treatment  of  Contractions  and  of  Strictures  at  and  just  within 
the  Meatus. — By  a  wise  provision  of  Nature  the  end  of  the  urethral 
canal  is  so  much  narrowed  that  the  stream  of  urine  is  projected  well  in 
advance  of  the  body  and  in  a  solid  jet,  in  accordance  with  hydraulic 
principles.  Exceptionally  cases  are  met  with  in  which  there  is  a  greater 
or  less  abnormal  contraction  of  the  meatus.  When  this  is  only  moder- 
ate, there  may  be  no  disturbance  in  the  function  of  urination  ;  but  in 
some  cases  the  meatus  is  exceedingly  small,  even  of  a  pinhead  size,  and 
then  much  functional  disturbance  may  result.  The  prominent  symp- 
toms in  cases  of  very  small  meatus  are  frequent,  painful,  and  prolonged 
micturition  and  deep-seated  urethral  uneasiness  or  irritation,  together 
with  vesical  irritability.  In  some  seemingly  well-observed  cases  such 
symptoms  as  anterior  crural  neuralgia  and  sciatica  have  been  found. 
Many  incorrect  and  exaggerated  statements  have  been  made  as  to  the 
serious  conditions  which  often  accompany  contracted  meatus.  Thus  it 
is  stated  that  the  anomaly  gives  rise  to  pain  in  the  back  and  hypogas- 
trium,  groins,  and  testes,  to  hydrocele,  to  painful  seminal  emissions,  and 
to  paresis  and  softening  of  the  brain.  The  truth  of  the  matter  is  about 
as  follows  :  In  men  free  from  gonorrhoea  or  urethral  irritation  the  uri- 
nary functions  may  be  perfectly  performed  even  if  the  meatus  is  no 
larger  in  calibre  than  10  French,  and  there  may  be  no  abnormal 
symptoms. 


200  STRICTURE  OF  THE   URETHRA. 

The  logical  deductions  warranted  by  the  foregoing  facts  and  con- 
siderations are — 1,  that  when  an  abnormally  small  meatus  causes  a 
decided  impairment  of  the  urinary  function,  it  should  be  cut  in  a  con- 
servative manner ;  2,  that  when  the  smallness  of  the  urethral  orifice  is 
found  to  be  the  undoubted  cause  of  the  perpetuation  of  deep  urethral 
inflammation  of  any  kind,  it  should  be  enlarged  ;  and,  3,  that  when  the 
meatus  will  not  admit  of  instruments  sufficiently  large  to  act  upon 
deep-seated  urethral  lesions,  it  should  be  incised  in  keeping  with  the 
necessity. 

In  general,  the  contraction  of  the  meatus  is  due  to  the  excessive 
development  of  the  mucous  membrane  at  the  lower  commissure,  and 
exceptionally  a  septum  of  mucous  membrane  stretches  across  the  canal 
from  the  upper  commissure  and  encroaches  more  or  less  on  its  lumen. 
Consequently,  it  is  necessary  to  examine  each  case  by  separating  the  lips 
and  also  introducing  a  curved  probe  in  order  to  determine  whether  the 
incision  is  to  be  made  upward  or  downward.  The  part  having  been 
rendered  aseptic,  an  incision  should  be  very  carefully  made  exactly  in 
the  middle  line  by  means  of  a  straight  blunt  bistoury.  It  is  well,  as  a 
general  rule,  in  this  operation  of  meatotomy,  to  make  the  incision  large 
enough  to  admit  a  32  F.  meatus  sound,  supposing  that  the  urethra  will 
comfortably  admit  a  No.  30  F.  sound.  If  the  urethral  lumen  is  less 
than  30  F.,  it  is  well  to  cut  the  meatus  in  accordance  with  its  measure- 
ment. In  the  majority  of  cases  it  will  be  found  that  when  the  meatus 
finally  heals  the  calibre  will  be  about  two  sizes  smaller  than  the  meatot- 
omy made  it.  After  incision  of  the  meatus  pressure  will  usually  stop 
bleeding  in  a  short  time.  The  meatus  sound  (there  are  varying  sizes 
of  this  useful  little  instrument)  may  be  introduced  every  two  or  three 
days  for  several  weeks.  It  is  thus  necessary  to  keep  up  the  process  of 
dilatation,  since  these  parts  show  a  decided  tendency  to  promptly  recon- 
tract. 

Cicatricial  strictures  of  the  meatus  are  not  very  common,  and  in 
general  follow  the  initial  lesion  of  syphilis  when  seated  here.  In  many 
cases  of  chancre  of  the  meatus  the  urethral  lumen  is  not  at  all  impaired 
after  its  involution  ;  in  others  there  may  be  slight  contraction,  and  ex- 
ceptionally a  dense  fibrous  ring  is  left,  which  may  reduce  the  size  of  the 
orifice  to  No.  2  or  3  French  scale. 

Chancroidal  ulcers,  and  exceptionally  chronic  relapsing  herpes  pro- 
genitalis,  may  cause  cicatricial  stricture  of  this  orifice.  A  scleroderma- 
tous condition  and  keloid  may  also  cause  abnormal  contraction  of  the 
meatus  and  fossa  navicularis.  In  these  cases  of  stricture  due  to  new 
tissue-formation  the  incision  should  be  made  in  accordance  with  the  seat 
of  the  obstruction.  The  passage  of  a  probe  will  show  whether  (as  is 
generally  the  case)  it  is  necessary  to  make  an  upward  and  also  a  down- 


TREATMENT  OF  ANTERIOR  STRICTURES.  201 

ward  incision,  and  it  will  indicate  the  necessary  depth  of  the  cuts.  The 
subsequent  treatment  consists  in  the  careful  introduction  of  the  meatus 
sound.  This  operation  should  be  repeated  for  a  considerable  time,  some- 
times many  months,  until  all  tendency  (which  is  great)  to  recontraction 
has  ceased.  If,  as  a  result  of  this  operation,  the  meatus  will  admit  a 
No.  30  French  sound,  it  may  be  pronounced  to  be  satisfactory. 

Treatment  of  Stricture  in  the  Pendulous  Portion  of  the  Ure- 
thra.— The  urethra  from  the  penoscrotal  angle  to  the  meatus,  corre- 
sponding to  Regions  Nos.  2  and  3,  is  in  many  cases  the  seat  of  stricture, 
but  it  is  rather  less  frequently  affected  than  the  first  region,  which 
includes  the  bulbous  portion  of  the  canal. 

In  the  pendulous  urethra,  which  extends  to  the  penoscrotal  angle, 
many  changes  take  place  as  the  result  of  gonorrhoeal  inflammation  which 
should  be  separately  considered. 

For  purposes  of  description  it  is  well  to  study  urethral  contractions, 
inch  by  inch,  down  the  canal,  since  the  surgical  indications  and  require- 
ments vary  very  much  in  different  portions  of  the  anterior  canal. 

In  chronic  gonorrhoea  the  two  inches  of  the  urethra  just  beyond  the 
meatus  may  be  the  seat  of  soft  infiltration,  which  is  thus  limited  or 
which  may  be  continuous  with  a  morbid  condition  of  the  urethra 
beyond.  In  practice  we  not  uncommonly  find  strictures  of  this  part. 
They  may  be  met  with  in  the  semifibrous  or  well-developed  fibrous 
form.     Inodular  stricture  is  rarely  found  here. 

Semifibrous  strictures  of  the  segment  of  the  urethra  under  considera- 
tion may  be  much  benefited  by  dilatation  with  the  straight  steel  sound, 
provided  they  are  seen  early  enough.  As  a  rule,  however,  these  cases 
come  to  us  when  the  urethral  canal  is  the  seat  of  fibrous  infiltration, 
which  further  shows  itself  by  the  existence  of  one,  several,  or  many 
ring-like  bands.  The  canal  is  then  the  seat  of  fibrous  stricture,  which 
in  this  region  is  usually  very  dense  and  unyielding.  The  calibre  may  be 
15  to  3  or  4  French  scale,  and  the  bulb  introduced  and  withdrawn  bumps 
roughly  over  a  dense  membrane  with  contractions.  It  may  be  stated 
as  a  general  rule  that  in  these  cases  dilatation  is  not  to  be  used,  since  it 
will  produce  little  if  any  effect,  and  will  cause  pain  and  uneasiness. 

These  strictures  require  careful  incision,  for  which  purpose  Gouley's 
probe-pointed  bistoury  and  the  straight  blunt  bistoury  are  the  necessary 
instruments.  The  parts  having  been  thoroughly  cleansed,  cocaine  anaes- 
thesia may  be  produced  by  the  injection  into  the  urethra  of  a  10  per 
cent,  solution.  If  the  contraction  is  very  small,  the  canal  may  be 
widened  sufficiently  by  a  moderately  downward  cut  with  the  Gouley 
knife,  and  then  an  upward  and  a  downward  cut  exactly  in  the  median 
line  should  be  made  with  the  blunt  bistoury.  These  parts  never  should 
be  cut  recklessly,  either  into  the  space  between  the  cavernous  bodies 


202  STRICTURE   OF  THE   URETHRA. 

above  or  into  the  cellular  tissue  below.  If  after  this  simple  form  of 
internal  urethrotomy  a  No.  25  to  28  F.  straight  steel  sound  can  be 
introduced  readily  and  without  pain  to  the  patient,  the  result  may  be 
considered  good.  In  these  cases  it  is  utterly  impossible  to  fully  restore 
the  suppleness  of  the  urethral  walls,  but  much  can  be  done  by  careful 
dilatation  kept  up  long  after  the  incisions.  Stricture-tissue  in  this  por- 
tion of  the  urethra  is  very  prone  to  rapid  condensation  and  contraction ; 
hence  there  is  always  a  battle  in  these  cases  to  keep  the  urethral  canal 
of  moderately  large  size.  Though  some  authors  recommend  over-dila- 
tation and  a  general  vigorous  treatment  for  these  distal  strictures,  I  am 
firm  in  the  conviction  that  moderate  and  gradual  dilatation  up  to  25  F., 
and  perhaps  a  little  above,  will  in  the  end  give  the  patient  the  best 
results.  In  cases  of  large  urethra  perhaps  we  may  establish  a  calibre 
of  30  F.  This  however,  may  be  said,  that  if  five  years  after  this  little 
operation  the  patient  can  pass  a  jSTo.  25  F.  sound,  he  is  a  lucky  man. 

AVe  sometimes  meet  cases  in  which  the  contraction  is  from  one  to 
two  inches  down  the  canal,  and  a  15  French  bulb  passes  readily  beyond 
it.  For  these  cases  Civiale's  urethrotome  is  particularly  adapted. 
Localizing  the  fibrous  patch  or  band  by  means  of  the  expanded  portion 
of  the  instrument,  the  penis  is  rendered  tense  and  the  tissue  is  cut  on 
the  upper  wall  of  the  urethra  to  about  28  or  30  F.  Then  the  straight 
steel  sound  may  be  passed,  and  while  it  is  in  the  canal  moderate  press- 
ure may  be  exerted  on  the  morbid  tissue.  By  this  means  considerable 
absorption  may  be  produced. 

The  So-called  Strictures  of  Large  Calibre. 

Some  authors  claim  that  the  normal  urethral  calibre  is  much  greater 
than  that  given  in  this  work.  They  base  their  statements  on  the  fact 
that  the  urethra  may  be  dilated  by  the  urethrameter  up  even  as  high  as 
40  F.  They  further  make  the  claim  that  the  calibre  of  the  urethra  is 
or  should  be  uniform  in  its  whole  course ;  consequently  if  a  urethra- 
meter  is  introduced  into  a  canal  and  screwed  up  to,  say  36  F.,  accord- 
ing to  these  views  this  expanded  bulb  should  pass  smoothly  out  when 
the  instrument  is  withdrawn.  If,  however,  the  instrument  hitches  or 
halts  or  jumps  over  moderate  obstructions,  these  narrowed  parts  are 
called  strictures,  and  the  patient  is  told  that  he  has  one  or  more  strict- 
ures of  large  calibre.  The  trouble  with  this  matter  of  strictures  of 
large  calibre  is  that  the  assumptions  regarding  them  are  based  on  con- 
clusions drawn  from  the  use  of  the  urethrameter,  and  on  theories  as  to 
the  nature  of  stricture  of  the  urethra.  This  whole  subject  is  cleared  up 
by  a  full  knowledge  of  the  arrangement  of  the  muscular  fibres  of  the 
urethra. 


THE  SO-CALLED  STRICTURES  OF  LARGE  CALIBRE. 


203 


The  facts  are  as  follows :  Outside  of  the  mucous  layer  of  the  urethra 
are  two  muscular  layers  which  extend  from  the  vesical  orifice  to  the 
meatus,  being  particularly  strong  and  thick  in  the  prostatic  urethra. 
The  outer  muscular  layer  consists  of  fibres  forming  distinct  rings, 
while  the  inner  muscular  layer  consists  of  longitudinal  fibres.  When  the 
penis  is  in  a  flaccid  condition  these  muscular  fibres  lie  rather  near 
together,  but  when  it  is  erect,  and  when  the  urethra  is  much  distended, 
they  are  stretched  apart.  The  longitudinal  muscular  fibres  in  the 
torpid  condition  of  the  penis  contract  mildly  and  shorten  the  urethral 
canal,  and  throw  it  into  transverse  folds,  while  the  ringed  fibres  bring 
the  walls  into  such  a  collapsed  condition  that  the  urethra  is  converted 
into  a  long  thin  slit.  Now,  when  the  urethra  is,  in  the  dead  subject, 
injected  with  some  hardening  fluid,  and  the  canal  is  then  dissected  out, 
it  presents  the  appearance  shown  in  Fig.  51.     It  will  be  seen  that  the 

Fig.  51. 


Shows  a  normal  urethra  distended  with  solidifying  injection-material.    The  contractions  corre- 
spond to  the  circular  rings  of  muscular  fibres. 


canal  is  both  elongated  and  much  distended,  and  that  at  quite  regular 
intervals  there  are  certain  depressions  which  show  decided  contractions 
(about  eleven  in  number)  in  its  continuity.  Now,  these  constrictions 
are  caused  by  the  resistance  of  the  muscular  rings,  which  are  forced 
widely  apart  and  put  on  the  stretch.  Between  these  muscular  rings  the 
dilated  portions  consist  of  mucous  membrane  and  its  ambient  fibrous 
tissue.  Now,  when  we  apply  these  anatomical  facts  to  clinical  observa- 
tion and  instrumental  examination,  many  points  which  have  until  now 
been  obscure  are  rendered  clear.  These  muscular  rings  will  allow  of 
very  considerable  stretching  by  the  urethrameter,  but  they  finally  offer 
resistance,  while  the  tissues  between  them,  being  less  firm  and  more 
extensible,  yield,  and  as  the  bulb  of  the  instrument  is  drawn  out  it  is 
held  by  a  muscular  band  on  its  proximal  end,  and  this  contraction  is 
then,  by  many,  pronounced  to  be  stricture.  Consequently,  I  say  that 
surgeons  imbued  with  the  belief  that  the  normal  calibre  of  the  urethra 
is  much  above  30  F.,  and  that  the  lumen  of  the  canal  in  health  is 
unvaryingly    uniform    in    calibre,    can    find    strictures    in    the    urethra 


204 


STRICTURE   OF  THE   URETHRA. 


of  any   man    if  they  will   only  expand   the   bulb   of  the   instrument 
strongly  enough. 

Undoubtedly  cases  do  occur  in  which  true  strictures  of  large  cal- 
ibre exist,  but  they  are  rather  rare.  In  Fig.  52  is  clearly  portrayed 
a  thread-like  semifibrous  stricture 
which  was  seated  in  the  urethral  wall 
three  inches  down  on  its  lateral  por- 
tion, extending  nearly  but  not  up  to 
the  median  line.     Now,  this  is  a  fair 

Fig.  52. 


Fig.  52.— Thread-like  stricture  involving  only  a  portion  of  the  circumference  of  the  urethra. 

Fig.  53.— Showing  firm  fibrous  stricture  in  the  middle  of  the  pendulous  urethra,  dilatation  of  the 
canal  behind  it,  inodular  stricture  at  the  bulb,  abscess  of  the  prostate,  hypertrophy  of  the 
bladder,  and  dilatation  of  orifices  of  the  ureters.  (From  the  Museum  of  the  College  of 
Physicians  and  Surgeons,  New  York.) 

representation  of  strictures  of  large  calibre.  This  one  formed  only  the  seg- 
ment of  a  circle,  and  more  extensive  ones  form  more  or  less  perfect  rings. 
It  will  be  seen  that  if  the  surgeon  had  attempted  to  incise  this  stricture 
by   means    of    the   dilating    urethrotome,   it   would    have   escaped   the 


STRICTURES  OF  THE  PENDULOUS   URETHRA.  205 

cutting  blade,  which  follows  the  median  line  almost  exactly.  This 
occurrence,  therefore,  is  very  significant,  and  points  out  the  necessity  of 
thorough  examination  in  all  cases.  When  the  bulb  of  the  bougie  ct 
boule  was  slipped  over  this  contraction,  the  sensation  was  conveyed  as 
if  it  was  held  by  a  distinct  band  or  ring.  The  same  sensation  is  con- 
veyed when  only  a  segment  of  the  urethral  ring  is  thickened  from 
hyperplasia ;  and  in  many  cases,  if  the  diagnosis  is  thus  wholly  based 
on  the  finding  of  the  bougie  a  boule,  the  conclusion  may  be  reached  that 
an  annular  stricture  is  present,  when  really  only  a  portion  of  the  ure- 
thral lumen  is  thickened  and  less  distensible  than  it  is  normally.  Con- 
sequently, it  is  necessary  to  carefully  palpate  the  urethra  with  the 
finger-tip  over  the  shaft  of  the  bougie  in  the  canal  in  order  to  discover 
areas  of  new  tissue,  and  in  some  cases  to  examine  the  urethra  with  the 
endoscope.  Before  making  a  diagnosis  of  stricture  of  large  calibre  the 
surgeon  must  convince  himself  beyond  all  doubt  that  the  contraction  is 
there,  that  it  is  not  due  to  localized  soft  inflammatory  deposits,  and  that 
by  his  instrument  he  can  reach  and  incise  it. 

Assuming  that  a  stricture  or  strictures  in  ring  or  band  form  have 
been  found,  the  surgeon  has  at  his  command — 1,  Civiale's  urethrotome, 
which  with  practice  becomes  a  very  efficient  instrument,  and  by  which 
the  constriction  can  be  very  accurately  cut ;  and  2,  Otis's  dilating  ure- 
throtome, which  when  judiciously  used  will  cut  with  much  accuracy 
and  without  damage  to  the  urethra  beyond  the  strictured  part. 

Tight  semifibrous  and  fibrous  strictures  are  not  infrequently  found 
in  the  pendulous  urethra.  In  Fig.  53  is  very  clearly  shown  a  firm 
stricture  about  three  inches  from  the  meatus.  This  figure  is  worthy  of 
study,  and  the  following  points  may  be  noted  :  The  urethra  behind  the 
stricture  is  dilated  and  its  wall  thinned  ;  at  the  bulb  are  several  bands 
and  much  sclerosis  of  the  mucous  membrane ;  at  the  prostate  there  is 
an  abscess,  and  the  bladder- walls  are  much  thickened.  It  is  not  un- 
common to  find  a  single  anterior  stricture  like  the  one  here  pictured, 
but  I  think  it  is  more  common  to  find  the  pendulous  urethra  the  seat 
of  extensive  (as  to  length)  coarctation,  in  which  there  may  be  several, 
even  many,  bands.  In  these  cases  the  urethral  canal  anterior  to  the 
penoscrotal  angle  is  densely  infiltrated,  and  these  bands  are  simply  the 
more  prominent  evidences  of  the  morbid  process. 

In  the  treatment  of  these  strictures  in  the  anterior  urethra  much 
judgment  and  skill  must  be  exercised.  It  is  always  well  not  to  do  too 
much  in  these  cases.  When  the  stricture-tissue  is  quite  firm,  Ave  never 
can  restore  the  urethra  to  its  normal  condition.  Our  function  in  these 
cases  is  to  tunnel  a  moderately  large  passage,  and  then  to  try  to  keep  it 
open.  For  these  cases  there  is  no  more  useful  instrument  at  hand  than 
Fluhrer's  modification  of  Maisonneuve's  urethrotome,  using  the  blade 


206  STRIC1UBE  OF  THE   URETHRA. 

which  will  cut  a  passage  for  a  22  sound  or  bougie.  When  this  opera- 
tion is  performed  the  treatment  may  be  said  to  have  just  begun. 
Thereafter  the  sound  must  be  regularly  introduced  about  once  a  week  or 
less  frequently.  If  in  these  cases  the  patient  is  left  with  a  canal  which 
will  admit  a  20  or  23  F.  sound,  and  his  bladder  is  healthy,  the  result 
may  be  pronounced  very  satisfactory.  Some  surgeons  recommend  over- 
dilatation,  sometimes  applied  with  much  force,  in  these  cases;  but,  as  a 
rule,  such  measures  only  stimulate  the  process  of  recontraction,  and 
they  should  not  be  used.  With  the  dilatation  treatment  subsequent  to 
incision  medication  may  be,  if  necessary,  applied  to  the  posterior  urethra 
and  bladder,  and  indeed  to  any  complication  which  may  exist. 

In  these  cases  the  bulbous  urethra  may  also  be  involved,  and  it  will 
require  suitable  treatment. 

Treatment  of  Strictures  beyond  the  Penoscrotal  Angle. — By  far 
the  greater  number  of  strictures  will  be  found  just  beyond  the  peno- 
scrotal angle,  as  far  back  as  the  bulbomembranous  junction.  In  treat- 
ing this  deeply-seated  region  it  is  a  golden  rule  only  to  use  the  knife  as 
a  last  resort. 

In  the  chapter  on  Chronic  Urethritis  directions  are  given  (see  pp. 
80,  et  seq.)  for  the  treatment  of  the  lesions  of  the  anterior  urethra, 
which  should  be  remembered. 

Strictures  of  the  bulbous  portion  of  the  urethra  may  be  soft,  semi- 
fibrous,  and  modular,  all  of  which  require  appropriate  treatment. 

Soft  and  semifibrous  strictures  should,  as  a  rule,  never  be  incised 
until  milder  means  have  been  tried  and  have  failed. 

The  diagnosis  having  been  carefully  made,  the  calibre  of  the  strict- 
ure is  to  be  determined.  Now,  on  this  point  no  rule  can  be  laid  down, 
since  cases  differ  so  strikingly.  Thus  in  some  patients  the  canal  may 
be  reduced  to  20  or  15  F.,  and  yet  these  strictures  are  of  the  soft 
variety.  In  others,  with  similar  calibres,  they  may  be  semifibrous  or 
fibrous.  Then,  again,  it  is  not  very  uncommon  to  find  a  urethra  reduced 
even  to  6  or  8  F.  by  an  exudative  hyperplasia  which  we  call  soft  strict- 
ure. These  various  and  varying  conditions  have  to  be  ascertained,  and 
as  the  surgeon  grows  in  experience  he  will  become  more  and  more 
expert  in  recognizing  them. 

Gradual  Dilatation. — W7hen  the  stricture  in  the  bulbous  urethra 
is  yet  in  the  soft,  or  even  in  the  semifibrous  stage,  the  aim  should  be  to 
remove  as  far  as  possible  the  cell-infiltration,  and  to  thus,  in  a  manner, 
restore  the  mucous  membrane  to  its  natural  condition.  This  can  be  done 
in  many  cases  by  careful  and  gradual  dilatation. 

Seeing  that  a  soft  stricture  may  contract  the  urethral  lumen  even  as 
low  as  7  or  8  F.,  and  that  in  many  cases  where  the  calibre  is  15  or  20 
F.  the  infiltration  is  yet  soft  and  succulent,  it  is  always  well  to  make  the 


GRADUAL  DILATATION.  207 

attempt  to  cure  by  the  introduction  of  the  bougie  or  sound  before  the 
knife  is  resorted  to.  When,  however, -a  fibrous  or  modular  stricture  of 
small  calibre  is  discovered,  our  chief  thought  is  not  toward  gradual 
dilatation. 

I  have  in  so  many  instances  been  able  to  restore  the  urethra,  even 
when  contracted  to  7  or  8,  to  30  F.  that  I  am  always  loth  to  operate 
more  radically. 

In  the  process  of  gradual  dilatation  much  care,  patience,  and  good 
judgment  are  necessary.  The  operation  should  always  be  carefully  and 
slowly  performed  in  a  manner  to  cause  no  pain  or  uneasiness  and  no 
damage  to  the  tissues.  By  the  pressure  and  stimulation  of  the  distend- 
ing instrument  we  hope  to  cause  the  absorption  of  the  exudation  and  to 
give  tone  and  resiliency  to  the  dilated  vessels.  It  will  thus  be  seen 
that  we  are  always  liable  to  cause  inflammation,  and  this  condition  will 
either  delay  the  cure  or  perhaps  thwart  our  efforts.  In  cases  where  the 
contraction  is  as  great  as  7  or  8  F.,  and  also  where  the  calibre  of  the 
stricture  is  much  larger,  there  may  be  posterior  urethritis  or  even  ure- 
throcystitis, and  these  conditions  should  receive  proper  treatment. 

Beginning  with  a  small  olivary  bougie,  the  surgeon  should  gradually 
and  slowly  increase  the  size  of  the  instrument  as  the  progress  of  the 
case  will  indicate  to  him.  In  the  early  part  of  the  treatment  the  bougie 
may  be  introduced  once  a  week,  and  then  in  favorable  conditions  the 
interval  may  be  fixed  at  about  five  days.  It  is  almost  always  well  to 
allow  this  interval  of  time  to  elapse  between  the  stances  of  treatment. 
Many  men  have  failed  in  this  method  of  treating  stricture  by  the  too 
frequent  introduction  of  the  instrument,  and  many  patients  have  not 
received  the  benefit  they  would  have  if  there  had  been  less  haste.  In 
gradual  dilatation,  particularly  in  the  early  stages,  the  sensations  of  the 
patient  should  be  carefully  considered,  and  the  urine  regularly  and  meth- 
odically examined.  If  the  operation  causes  uneasiness  and  pain  in  the 
perineum  and  over  the  pubes  and  continued  frequency  in  urination,  and 
if  the  parts  resist  the  gradual  increase  in  the  size  of  the  instrument,  it 
will  be  necessary  to  suspend  the  treatment  temporarily,  and  perhaps 
permanently.  In  many  of  these  cases  local  medication  to  the  anterior 
and  posterior  urethra  will  put  the  parts  in  such  a  condition  that  gradual 
dilatation  may  again  be  resumed. 

It  will  be  generally  found,  when  dilatation  is  commenced,  in  the  form 
of  stricture  under  consideration,  with  very  small  olivary  bougies,  that  at 
first  the  sizes  may  be  increased  quite  regularly,  and  no  trouble,  or  per- 
haps very  little,  is  experienced  by  the  surgeon  until  he  gets  up  as  high 
as  20  or  22  F.  Then  he  will  generally  find  that  the  dilating  process 
will  go  on  much  more  slowly,  and  that  it  may  be  necessary  to  introduce 
sounds  of  one  size  several  times  before  larger  ones  can  be  used. 


208  STRICTURE   OF  THE   URETHRA. 

When  in  the  course  of  this  treatment  the  urethra  will  admit  an  oli- 
vary bougie  of  a  size  about  No.  20  F.,  it  is  well  to  resort  to  the  curved 
steel  sounds  and  with  them  finish  the  cure.  In  many  cases  when  the 
coarctation  is  extensive  and  involves  the  whole  length  of  the  bulbous 
urethra,  the  Beneque'  sound  will  produce  particularly  good  results.  Its 
double  curve  seems  to  exert  a  beneficial  pressure  not  obtainable  by  the 
use  of  the  ordinary  curved  sound. 

When  the  sound  causes  inflammatory  reaction,  its  use  should  be  dis- 
continued until  appropriate  treatment  removes  the  tendency  thereto,  as 
it  will  in  most  cases.  Exceptionally,  however,  it  happens  that  the  result- 
ing inflammation  is  so  great  and  so  constant  that  it  is  necessary  to  wholly 
abandon  this  form  of  treatment.  In  many  such  cases  judicious  topical 
urethral  medication  after  a  time  brings  about  such  a  change  that  the 
sound  may  be  used  again.  In  some  severe  and  exceptional  cases  the 
expediency  of  external  urethrotomy  will  suggest  itself  to  the  mind  of 
the  surgeon. 

There  is  one  point  which  deserves  especial  emphasis,  and  it  is  this  : 
To  produce  lasting  and  permanent  results  by  gradual  dilatation  the  ure- 
thral canal  must  be  brought  up  to  the  calibre  of  30  or  perhaps  32  F. 
and  when  this  is  attained  the  dilating  process  must  be  continued  for 
some  time,  until  these  large  sounds  pass  easily  and  without  any  grasping' 
It  is  impossible  to  exactly  state  the  period  of  time  necessary  for 
gradual  dilatation,  since  it  varies  in  each  case  and  much  depends  on  the 
regularity  of  attendance  of  the  patient.  In  some  cases  the  normal 
urethral  lumen  may  be  restored  in  three  months,  and  in  others  in  six, 
nine,  and  twelve  months.  As  a  general  rule,  a  six-months'  treatment 
will  be  followed  with  better  results  than  a  shorter  course. 

In  the  majority  of  cases  the  process  of  cure  by  gradual  dilatation  is 
uneventful,  but  in  a  small  minority  certain  complications  may  arise  and 
give  more  or  less  trouble.  These  complications  are — 1,  fever  and  chills ; 
2,  urethritis  and  urethrocystitis  ;  3,  a  tendency  to  hemorrhage ;  4,  tem- 
porary retention  ;  5,  rheumatism  ;  and  6,  pyaeniic  abscess.  It  is  well  to 
state  in  advance  that  since  the  beginning  of  the  era  of  asepsis  and  anti- 
sepsis in  surgery  these  complications  occur  much  less  frequently  than 
formerly  and  they  are  much  less  severe. 

The  occurrence  of  chills  and  fever  shows  that  there  is  a  low  grade 
of  suppuration  in  the  deep  urethra,  but  it  need  not  cause  the  permanent 
discontinuance  of  dilatation.  Such  cases  should  be  treated  on  the  lines 
laid  down  for  chronic  anterior  and  posterior  urethritis  and  urethro- 
cystitis. 

In  like  manner,  the  tendency  to  slight  oozing  of  blood  after  dilata- 
tion can  generally  be  checked  by  the  instillation  of  a  few  drops  of  a 
solution  of  nitrate  of  silver  (1  :125). 


INTERNAL    URETHROTOMY.  209 

When  in  the  course  of  gradual  dilatation  retention  of  urine  occurs 
once  or  at  intervals,  it  is  perfectly  certain  that  one  or  two  causes  are  at 
work  :  these  are  swelling  of  the  mucous  membrane  in  and  near  the 
stricture  and  temporary  spasm  of  the  compressor  urethras  muscle.  In 
such  cases  there  is  need  of  topical  urethral  medication,  and  the  intervals 
between  the  passage  of  the  bougies  or  sounds  should  be  materially 
lengthened.  When  carefully  managed  this  complication  may  be  over- 
come. 

The  very  rare  occurrence  of  rheumatism  and  of  pysemic  abscesses 
indicates  very  clearly  that,  besides  the  stricture-process,  a  decided  suppu- 
ration of  the  urethra  also  exists,  which  can  be  cured  by  the  means 
described  in  the  section  on  the  treatment  of  chronic  anterior  and 
posterior  urethritis. 

The  main,  and  indeed  the  only,  valid  objection  to  gradual  dilatation 
is  that  it  is  a  slow  process  and  occupies  quite  a  long  stretch  of  time. 
But  it  must  always  be  remembered  that  if  it  is  followed  up  until  the 
urethra  is  restored  to  a  calibre  of  30  F.;  in  the  majority  of  cases  it  will 
only  be  necessary  to  have  sounds  introduced  once  or  twice  a  year  there- 
after ;  whereas  it  can  be  said,  without  fear  of  contradiction,  that  when 
a  man's  urethra  has  once  been  cut  he  has  (if  he  would  keep  the  channel 
open)  to  pass  instruments  at  short  intervals  all  his  life. 

Continuous  Dilatation. — Continuous  dilatation  is  very  rarely 
resorted  to  at  the  present  time.  In  some  cases  where  a  filiform  has 
after  a  long  struggle  been  passed  through  the  stricture,  it  may  be  re- 
tained there  for  some  hours  or  perhaps  for  a  day,  in  order  to  render 
certain  the  passage  of  a  larger  instrument. 

Strictures  at  and  just  beyond  the  penoscrotal  angle  are  frequently 
formed  of  the  dense  fibrous  variety.  These  strictures  sometimes  under 
treatment  become  tolerably  well  dilated,  and  then  they  recontract  more 
or  less  promptly  ;  hence  they  are  called  "  resilient  strictures." 

Rapid  dilatation  is  sometimes  necessary,  and  is  readily  accom- 
plished by  passing  over  a  filiform  introduced  into  the  bladder  tunnelled 
sounds  in  increasing  number  until  a  calibre  of  10  to  15  F.  is  reached 

In  marked  contradistinction  to  the  curability  of  the  soft  and  semi- 
fibrous  strictures  beyond  the  penoscrotal  angle  are  the  fibrous  and 
modular  undilatable  strictures  of  this  region,  which  for  relief  require 
the  radical  operations  of  internal  or  external  urethrotomy. 

Internal  urethrotomy  in  the  deep  urethra  may  be  performed 
with  certain  restrictions  in  a  limited  number  of  cases.  This  procedure 
may  be  resorted  to  in  cases  of  tight,  not  extensive,  decidedly  annular, 
fibrous  stricture  just  at  and  about  one  inch  beyond  the  penoscrotal  junc- 
tion, and  perhaps  at  the  bulbomembranous  junction,  particularly  if  the 
stricture  is  not  a  very  large,  dense,  and  modular  one. 

14 


210 


STRICTURE   OF  THE    URETHRA. 


Fig.  54. 


Fig.   54  gives  a  very  clear  idea  of  a  severe  ease  of  tight  stricture 
just  beyond   the  penoscrotal  angle,  with  involvement    of   the    greater 

portion  of  the  pendulous  urethra. 
It  is  evident  that  in  such  a  case 
dilatation  by  sounds  would  be  pain- 
ful and  futile,  and  that  the  only  pro- 
cedure advisable  would  be  to  tunnel 
a  channel  by  means  of  a  cutting 
instrument.  The  oval  black  spot 
just  behind  the  stricture  shows  the 
distal  end  of  a  false  passage. 

In  former  years  internal  ureth- 
rotomy by  means  of  Maisonneuve's 
instrument  was  largely  performed  in 
cases  of  stricture  in  Eegion  Xo.  1. 
My  experience  has  taught  me  to 
limit  its  use  to  the  fibrous  strictures 
in  the  segment  of  the  urethra  just 
named.  The  patient,  being  healthy, 
having  normal  kidneys,  and  not 
much  if  any  bladder  trouble,  should 
be  put  on  moderate  diet  for  a  day  or 
two  and  kept  in  bed,  during  which 
time  the  urethra,  and  if  possible  the 
bladder,  should  be  well  irrigated 
several  times  with  quite  hot  saturated 
boric  or  salt  solution.  The  night  before 
the  operation  he  should  have  a  brisk 
cathartic.  AYhen  antisepsis  can  be 
practised  there  is  no  need  for  the 
internal  use  of  boric  acid,  salol,  or 
quinine  :  still,  there  are  no  objections 
to  the  employment  of  these  drugs  if 
the  surgeon  so  wishes.  If  the  patient 
is  a  weakly  man,  he  should  be  pre- 
pared some  time  ahead,  by  care  as  to 
diet  and  tonics,  for  the  operation. 
The  patient   is  prepared,  ether- 

trophied,  orifices  of  ureters  dilated.  (From    ized,  and  placed  on  his  back,  then  the 

the  Museum  of  the  College  of  Physicians     filiform    guide    of    the    Maisonueiive 

and  Surgeons,  New  York.)  .  .  ,  , 

instrument  should  be  passed  accord- 
ing to  directions  already  given,  and  followed  by  the  grooved  conductor 
and  the  knife.     Before  every  internal  urethrotomy,  just  at  the  time  of 


Showing  dense  fibrous  stricture  of  the  ure- 
thra just  beyond  the  penoscrotal  angle, 
with  dilatation  of  the  bulbous,  membran- 
ous, and  prostatic  urethra.  The  pendu- 
lous urethra  is  also  much  thickened  and 
infiltrated.  Walls  of  bladder  much  hyper- 


INTERNAL    URETHROTOMY.  211 

use,  the  surgeon  should  pass  the  cutting  part  of  the  instrument  clown  the 
grooved  conductor,  in  order  to  be  absolutely  certain  that  there  will  be  no 
impediment.  If  the  soft  French  filiform  should  kink  or  curl  up  and 
come  back,  the  surgeon  should  screw  on  the  eyed  or  tunnelled  tip.  Then, 
having  passed  a  long  whalebone  filiform,  he  should  slip  the  eye  of  the  con- 
ductor over  this  guide,  and  then  cause  the  instrument  to  glide  slowly  into 
the  bladder.  Always  before  adjusting  the  cutting  blade  of  the  instrument, 
which  is  directed  toward  the  roof  of  the  urethra  in  the  median  line,  the 
surgeon  should  put  his  finger  in  the  rectum,  when,  if  everything  is  all 
right,  he  will  feel  the  conducting  staff  in  the  membranous  urethra,  and 
the  end  of  the  instrument  can  then  be  freely  moved  in  the  vesical 
cavity.  "When  the  urethrotomy  is  performed  the  instrument  should  be 
held  in  the  line  of  the  thighs.  It  is  never  well  to  use  a  large  cutting 
blade.  Too  deep  incisions  may  be  followed  by  hemorrhage  and  per- 
haps urinary  infiltration  and  fever.  My  custom  for  years  has  been  to 
cut  the  urethra  to  the  extent  of  21  F.,  and  on  the  withdrawal  of  the 
urethrotome  to  pass  an  olivary  bougie  catheter,  No.  21  F.,  with  a  very 
small  opening  on  its  extreme  end  (not  the  ordinary  gum-elastic  catheter, 
whose  eyes  irritate  and  tear  the  urethra),  into  the  bladder,  and  to  allow 
any  contained  urine  to  run  out,  and  then,  by  means  of  a  hand  syringe, 
to  inject  five  to  eight  ounces  of  warm  boric  solution,  and  there  leave  it. 
This  antiseptic  solution,  when  voided  later  on,  thoroughly  bathes  the 
wound  and  is  productive  of  much  good. 

The  bougie-catheter  may  be  introduced  again  in  about  two  or  four 
days,  and  then  the  bladder  should  be  injected  again.  With  the  urethra 
thus  enlarged  gradual  dilatation  may  soon  be  commenced,  and  should 
be  carried  on  until  a  calibre  of  30  F.  is  produced.  After  that  it  is  well 
to  introduce  the  sound  at  intervals  of  a  week,  a  fortnight,  or  a  month, 
and  perhaps  several  months,  as  the  progress  of  the  case  indicates. 

Internal  urethrotomy  thus  performed  in  appropriate  cases  will  not  be 
attended  with  suffering  or  disaster  to  the  patient,  and  will,  if  properly 
followed  up,  be  productive  of  great  benefit. 

Since  there  is  much  confusion  as  to  the  title  and  scope  of  the  various 
operations  in  the  perineum  for  stricture  and  other  conditions,  it  is  well 
to  try  to  present  a  sharply-marked  division  of  them.  These  operations 
may  be  divided  as  follows  :  1,  external  urethrotomy  with  a  tunnelled 
sound  for  bladder  drainage,  etc. ;  2,  external  urethrotomy  with  filiform 
guide  through  the  stricture,  down  to  the  face  of  which  or  beyond  a 
tunnelled  instrument  has  been  passed  (this  is  the  Gouley  operation) ;  3, 
external  urethrotomy  with  the  staff  passed  down  to  the  stricture  without 
a  guide  through  it  (this  is  the  Wheelhouse  operation)  ;  4,  external  ure- 
throtomy without  any  instrument  in  the  urethra,  the  membranous  por- 
tion being  incised  (this  is  generally  known  as  Cock's  operation  or  perineal 
section). 


212  STRICTURE  OF  THE   URETHRA. 

External  Urethrotomy  for  Drainage,  etc. — This  operation 
is,  as  a  rule,  very  simple  in  its  performance,  since  there  is  usually  no 
impediment  to  the  passage  of  the  sound.  The  patient  having  been  pre- 
pared and  etherized  and  placed  in  the  lithotomy  position,  the  sound  is 
passed  into  the  bladder.  The  scrotum  is  held  up  by  an  assistant,  who 
also  holds  the  sound  and  causes  its  grooved  convexity  to  bulge  out  the 
perineal  tissues.  The  surgeon  then  with  a  scalpel  carefully  incises,  to 
the  extent  of  two  inches,  layer  after  layer  until  the  urethra  is  reached 
and  opened  longitudinally  about  three-fifths  of  an  inch  or  an  inch. 
Then  the  bladder  may  be  washed  out,  and  a  large  catheter  or  perineal 
tube  inserted  and  retained.  This  operation  is  also  performed  for  the 
removal  of  calculi  lodged  in  the  membranous  or  prostatic  urethra  and 
of  prostatic  concretions,  and  for  the  digital  exploration  of  these  parts, 
the  vesical  orifice,  and  adjacent  tissue.  By  the  older  surgeons  this  oper- 
ation was  called  the  "  boutonniere." 

Gouley's  and  Wheelhouse's  operations  are  generally  performed  for 
the  relief  of  modular  strictures  near  and  at  the  bulbomembranous  junc- 
tion, and  less  frequently  for  fibrous  strictures  the  result  of  traumatism, 
or  soon  or  immediately  after  the  damaging  or  rupture  of  the  urethra 
from  accidents  which  lacerate  or  cut  through  the  bulbous  or  mem- 
branous portions  of  the  urethra. 

External  Urethrotomy  with  a  Guide. — Gouley's  Operation. — 
The  operating  table  must  be  in  front  of  a  window  admitting  plenty  of 
of  light. 

The  patient  should  be  prepared,  etherized,  and  placed  in  the  lith- 
otomy position.  Before  commencing  the  operation  the  surgeon,  seated 
on  a  low  stool,  examines  with  his  finger  in  the  rectum,  the  membranous 
urethra  and  the  prostate,  and  familiarizes  himself  with  their  condition. 

The  long  filiform  having  passed  through  the  stricture  into  the  blad- 
der, the  tunnelled  sound  (see  Fig.  48)  is  carefully  slipped  over  it,  and 
by  it  guided  down  to  the  face  of  the  stricture.  An  assistant  now  care- 
fully and  firmly  holds  the  end  of  the  sound  between  the  thumb  and 
the  forefinger  exactly  in  the  median  line  and  a  few  inches  above  the 
pubes  and  hypogastrium,  while  at  the  same  time  he  elevates  the  scrotum 
and  preserves  the  vertical  direction  of  the  perineal  raphe.  If  the  ure- 
thra is  not  too  deep,  and  if  the  perineum  is  not  too  much  thickened 
with  inflammatory  exudation,  the  assistant  may,  by  gentle  upward  press- 
ure on  the  sound  by  means  of  his  middle  finger  underneath  it,  make  the 
tissues  tense,  and  by  this  means  clearer  indications  are  given  to  the  sur- 
geon as  to  the  precise  position  of  the  sound  and  the  urethra.  The  sur- 
geon then  makes  an  incision,  leisurely  dividing  layer  after  layer  of  the 
tissues  in  the  median  line  from  the  base  of  the  scrotum  to  within  an 
inch  of  the  anus,  being  about  two  or  three  inches  in  length  and  involv- 


EXTERNAL    URETHROTOMY.  213 

ing  only  the  skin  and  superficial  fascia.  The  dissection  having  been 
carefully  carried  down  to  the  urethra,  the  surgeon  feels  for  the  groove 
in  the  curved  portion  of  the  sound  with  his  finger-nail.  He  then  enters 
the  urethra,  his  knife  being  held  at  right  angles,  and  cuts  slowly  and 
carefully  dowmvard  about  an  inch,  meanwhile  taking  care  that  the  fili- 
form guide  is  not  cut.  It  is  very  important  to  make  a  good  clean  cut 
into  the  urethra  by  a  continuous  stroke,  the  knife  not  being  withdrawn 
until  the  full  incision  is  made,  otherwise  the  canal  maybe  cut  in  several 
places.  Hemorrhage  is  usually  moderate,  and  is  readily  controlled  by 
clamps.  AVhen  the  urethra  is  opened  a  ligature  two  feet  long  is  passed 
through  each  cut  edge,  and  then  tied  at  the  end.  Thus  we  have  two 
retractors,  which  are  held  with  gentle  tension  by  two  assistants,  which 
take  up  no  space  in  the  wound  and  Avhich  allow  full  inspection  of  the 
field  of  operation.  At  this  time  the  sound  is  withdrawn  a  little,  so  as  to 
bring  into  view  the  black  guide,  alongside  of  which  the  small  grooved 
probe,  which  should  be  gently  curved  upward  toward  its  tip  in  accord- 
ance with  the  terminal  half  of  the  subpubic  curve,  should  be  passed 

Fig.  55. 


Arnott's  small  grooved  silver  probe  with  a  broad  handle,  which  can  be  bent  to  any  angle. 

into  the  bladder.  (See  Fig.  55.)  Then  in  this  groove  Gouley's  beaked 
bistoury  is  passed,  and  the  stricture  is  incised  on  its  upper  wall,  care 
being  taken  to  go  well  through  the  dense  stricture-tissue,  but  not  into 
the  connective  tissue  beyond.  The  probe  is  now  turned  so  that  its  groove 
looks  downward,  along  which  the  beaked  bistoury  is  again  passed,  and 
the  lower  wall  of  the  stricture  is  carefully  incised  (usually  a  little  less 
deeply  than  the  upper  wall).     (See  Fig.  56.) 

It  is  always  well  to  take  care,  when  the  urethra  is  opened  and  the 
parts  are  exposed,  not  to  let  the  guide  slip  out  or  to  withdraw  it  until  the 
grooved  probe  is  well  in  the  bladder  and  the  incision  of  the  upper  wall 

Fig.  56. 


Gouley's  beaked  bistoury. 

of  the  stricture  has  been  made.  Then  the  surgeon  is  master  of  the  situ- 
ation, and  the  guide  may  be  withdrawn.  In  some  cases  the  stricture- 
tissues  are  so  densely  fibrous  and  extensive  that  after  a  preliminary 


214  STRICTURE  OF  THE    URETHRA. 

slight  cut  with  the  beaked  bistoury  the  operation  may  be  completed 
more  satisfactorily  by  means  of  a  blunt  straight  bistoury. 

When  the  stricture-tissue  has  been  incised  Teale's  probe  gorget  is  an 
exceedingly  useful  instrument,  particularly  to  persons  not  very  familiar 
with  the  operation.     (See  Fig.  57.)     By  its  passage  the  parts  may  be 

Fig.  57. 


Teale's  probe  gorget. 

much  dilated,  and  by  this  means  much  aid  is  given  the  timorous  surgeon 
who  fears  to  cut  too  deeply.  By  means  of  the  probe  gorget  the  catheter 
or  perineal  tube  is  then  passed  into  the  bladder,  which  should  be  well 
irrigated  with  hot  boric  acid  or  salt  solution. 

The  catheter  or  perineal  tube  used  in  this  operation  should  be  quite 
large,  and  should  be  adapted  to  the  calibre  of  the  incised  canal.  As  a 
rule,  tubes  from  30  to  35  F.  should  be  introduced.  The  aim  of  the 
surgeon  now  is  to  allow  the  urethral  tissues  and  the  ambient  tissues, 
which  liave  previously  been  much  congested,  to  drain,  and  also  to  so  act 
upon  the  urethra  by  as  much  dilatation  as  possible  that  absorption  may 
be  produced  and  a  canal  with  a  satisfactory  lumen  shall  be  left.  To 
this  end  I  always,  if  possible,  allow  the  tube  to  remain  in  the  wound 
three  to  seven  days,  taking  care  that  the  bladder  is  well  irrigated  several 
times  daily,  and  applying  such  topical  treatment  as  may  be  necessary. 
The  tube  is  retained  in  the  wound  by  means  of  a  ligature  which  passes 
through  its  edges  and  the  wound  around  the  tube  is  carefully  packed 
with  iodoform  gauze,  over  which  are  placed  layers  of  absorbent  cotton 
and  gauze,  which  are  held  in  place  by  a  retentive  bandage.  The 
catheter  is  connected  by  means  of  a  glass  coupling  to  a  long  India- 
rubber  tube  (calibre  30  F.),  which  passes  to  a  large  bottle  suspended 
to  the  side  of  the  bed,  which  should  always  be  half  filled  with  1  :  20 
carbolic-acid  solution. 

During  the  progress  of  the  case  it  is  most  important  that  the  peri- 
neal wound  should  be  carefully  inspected  and  kept  in  a  healthy  condi- 
tion. If  indolent  granulations  appear  they  should  at  once  be  cauterized 
with  the  solid  stick  of  nitrate  of  silver. 

Xow-a-days,  with  our  more  perfected  technic  and  antiseptic  meas- 
ures, it  is  very  rare  to  see  any  bad  results  follow  external  urethrotomy. 


EXTERNAL    URETHROTOMY.  215 

There  may  be  a  very  slight  and  ephemeral  rise  in  temperature,  but 
only  in  very  bad  old  cases  with  vesical  and  renal  complications  do  we 
see  urinary  fever  and  sepsis ;  and  these  complications  are  much  rarer 
than  they  were  in  former  days.  Hemorrhage  is,  as  a  rule,  infrequent 
after  this  operation,  as  performed  now-a-days,  and  is  readily  controlled 
by  the  pressure  exerted  by  packing  the  wound  quite  tightly. 

Syme's  Operation. — What  is  known  as  Syme's  operation  is  prac- 
tically the  one  already  described,  except  that  the  instrument  used  in  the 
urethra  is  Syme's  staff.  This  instrument  is  grooved  for  half  an  inch  at 
the  distal  part  of  its  straight  portion  which  is  joined  by  the  curved  part, 
which  is  also  grooved.  This  curved  portion  at  its  commencement  is  of 
size  No.  8  F.,  and  at  its  tip  it  is  4  French  in  calibre.  This,  long,  thin 
curve  makes  the  instrument  very  difficult  to  properly  introduce  into 
very  tight  strictures,  even  in  skilled  hands,  and  it  has  been  known  to 
cause  death  by  making  false  passages.  So,  while  it  is  well  to  be 
familiar  with  Syme's  staff  on  account  of  its  history,  it  is  not  well  to 
employ  it  now  that  we  have  the  tunnelled  catheters  and  filiforms. 

External  Urethrotomy  without  a  Guide  through  the 
Stricture. —  Wheelhouse's  Operation. — When  the  patient  is  fully  pre- 
pared and  etherized  a  last  attempt  should  be  made  to  pass  a  filiform. 
This  failing  we  operate  without  the  aid  of  a  guide. 

Fig.  58. 


Wheelhouse's  staff. 

The  steps  in  the  operation  are  as  follows  :  The  patient  being  in  the 
lithotomy  position  the  Wheelhouse  staff  is  gently  introduced  down  to  the 
stricture  with  the  groove  looking  toward  the  surface  and  is  there  held  by 
an  assistant.  (See  Fig.  58.)  The  surgeon  makes  a  careful  dissection  in  the 
perineum  until  the  urethra  is  reached  and  it  is  then  opened  on  the  groove 
of  the  staff,  not  upon  its  point.  The  edges  of  the  urethra  are  then  retracted 
so  that  the  canal  is  clearly  exposed.  The  staff  is  then  slightly  withdrawn 
and  turned  so  that  its  button  is  hooked  into  the  upper  angle  of  the 
wound  which  is  then  further  put  on  the  stretch.  The  surgeon  then  has 
a  view  of  the  parts  in  front  of  the  stricture,  and  he  may  be  able  at  once 
to  introduce  the  grooved  probe  or  the  gorget  into  its  orifice,  or  he  may 
have  to  make  repeated  attempts  to  reach  the  bladder.  When  the 
instrument  has  traversed  the  stricture  (as  shown  by  its  freedom  of 
movement  in  the  bladder)  an  incision  on  the  upper  and  lower  wall  of 
the  canal  is  made  by  means  of  a  probe-pointed  bistoury  and  all  bands 
and  obstructions  are  divided.  The  canal  is  then  well  dilated  by  the 
forefinger  of  the  operator,  who  satisfies  himself  that  he  has  free  access  to 


216  STRICTURE   OF  THE   URETHRA. 

the  bladder-cavity.  The  subsequent  steps  of  the  operation  are  the  same 
as  those  followed  in  the  Gouley  operation. 

External  Urethrotomy  without  a  Guide  (Cock's  Opera- 
tion or  Perineal  Section). — For  the  very  worst  and  most  desperate 
class  of  cases  in  which,  either  as  a  result  of  chronic  stricture  or  of  trau- 
matism with  great  swelling  of  the  perineum  and  scrotum,  the  urethra 
anterior  to  the  triangular  ligament  has  been  obliterated,  or  in  which  the 
stricture  is  impassable  to  instruments,  the  operation  known  as  Cock's 
operation,  perineal  section,  and  external  urethrotomy  without  a  guide 
may  be  necessary. 

The  patient  is  prepared,  etherized,  and  placed  in  the  lithotomy  posi- 
tion. The  left  forefinger  of  the  surgeon  is  introduced  into  the  rectum 
and  its  tip  is  held  firmly  against  the  apex  of  the  prostate.  With  the 
right  hand  a  double-edged  knife  is  plunged  into  the  perineum  in  the 
median  line  about  an  inch  anterior  to  the  anus  and  is  carried  forward 
without  any  cessation  above  and  in  the  direction  of  the  finger-tip.  By 
an  upward  and  downward  movement  this  vertical  incision  may  be  made 
sufficiently  large  so  that  when  the  bladder  has  been  entered  through  the 
membranous  urethra,  a  probe  may  be  introduced  which  will  act  as  a 
guide  for  a  goodly-sized  gum-elastic  or  soft-rubber  catheter  which  is 
passed  into  that  viscus  and  is  then  firmly  retained.  By  means  of  fre- 
quent irrigations  with  hot  boric  solution  the  bladder  is  much  benefited, 
and  the  urethra  may  also  thus  be  treated.  In  a  few  days  the  swelling 
in  the  perineum  will  have  materially  subsided,  and  systematic  explora- 
tion of  the  urethra  may  then  be  attempted. 

Retrograde  Catheterization. — In  those  bad  cases  of  laceration 
and  rupture  of  the  urethra  and  much  damage  to  the  perineum  with  or 
without  fracture  of  the  pelvis,  in  which  it  is  impossible  to  find  the 
proximal  end  of  the  canal,  it  may  be  necessary  to  resort  to  retrograde 
catheterization.  This  operation  is  performed  as  fellows  :  The  parts  hav- 
ing been  rendered  surgically  clean,  a  suprapubic  incision  is  made  suf- 
ficiently large  to  allow  the  passage  of  the  index  finger  by  which  the 
internal  vesical  orifice  is  located.  Then  a  gum-elastic  catheter  or  bougie 
is  guided  through  the  bladder  into  the  urethra  and  passed  out  of  the 
proximal  end  of  the  ruptured  canal  in  the  perineum.  Having  thus 
located  the  proximal  end  it  is  usually  easy  to  pass  the  instrument 
through  the  distal  portion  of  the  urethra.  The  end  of  the  catheter  is 
then  cut  off  at  right  angles  and  retained  in  the  urethra  for  the  purpose 
of  draining  the  bladder.  Under  these  circumstances  the  surgeon,  if  he 
sees  fit,  can  use  the  bougie  or  catheter  as  a  guide,  and  can  then  approx- 
imate and  suture  the  torn  ends  of  the  urethra  together  and  thus  prevent 
the  formation  of  a  traumatic  stricture,  or  he  may  allow  the  wound  to 
granulate  and  heal ;  it  is  necessary  to  drain  the  bladder  as  is  done  in 
external  urethrotomy. 


ELECTROLYSIS  IN  STRICTURE.  217 

Method  of  Performing  Perineal  Section  without  a  Guide, 
advocated  by  C.  L.  Gibson. — The  parts  are  rendered  surgically  clean 
and  the  patient  is  placed  in  the  lithotomy  position.  Thorough  prelimi- 
nary irrigation  and  cleansing  of  the  rectum  are  most  essential.  A  suit- 
able speculum  is  introduced,  and  the  prostate  is  transfixed  internally 
from  the  rectum,  preferably  by  a  large,  sharp  hook,  which  is  driven 
firmly  through  the  prostatic  tissue.  The  speculum  is  now  withdrawn, 
leaving  the  hook  in  situ.  Median  perineal  section  is  then  performed, 
the  incision  being  extended  down  to  the  ordinary  depth  of  the  urethra. 
The  left  forefinger  is  now  introduced  into  the  wound.  As  the  assistant 
executes  a  series  of  gentle  tugs  on  the  hook,  one  readily  receives  the  sen- 
sation of  the  intermittent  tension  of  the  urethra  in  response  to  the  trac- 
tion on  the  prostate.  Keeping  the  forefinger  in  place,  the  surgeon  with 
the  other  hand  directs  the  bistoury  into  that  portion  of  the  deep  urethra 
which  is  thus  rendered  prominent ;  the  probe-pointed  director  readily 
glides  alongside  the  knife  into  the  lumen  of  the  urethra,  and  following 
it  the  small  metal  catheter  will  demonstrate  the  successful  access  to  the 
bladder.  The  performance  of  these  various  steps  requires  only  a  minute 
01  two. 

It  may  be  remarked  that  in  the  hands  of  an  experienced  surgeon  this 
procedure  may  prove  effective ;  but  it  should  never  be  adopted  without 
the  most  careful  antisepsis,  and  never  by  a  novice. 

Rupture  or  Divulsion. — This  is  to-day  practically  an  obsolete 
operation.  It  is  a  dangerous,  inexact,  and  unsurgical  procedure,  and 
its  performance  would  be  in  total  violation  of  the  present  trend  of 
thought  and  experience  in  genito-urinary  surgery  which  teaches  that 
damage,  even  slight,  to  the  genito-urinary  tract  must  be  sedulously 
avoided. 

Electrolysis. — The  old  method  of  electrolytic  treatment  of  strict- 
ure need  only  be  mentioned  to  be  condemned.  A  moment's  thought  of 
the  pathological  condition  to  be  treated  in  stricture  of  the  urethra,  and 
of  the  mode  of  action  of  this  electrochemical  method  of  decomposition, 
will  convince  any  one  of  its  futility,  even  harmfulness,  if  thoroughly 
used.  The  aim  of  this  treatment  is  to  decompose  the  newly-formed 
morbid  tissue  and  to  produce  its  absorption  by  means  of  a  metal  bulb 
affixed  to  a  flexible  bougie  through  which  the  current  is  passed.  Now, 
electrolysis  has  not  an  electro-affinity  for  the  stricture-tissue,  leaving  the 
mucous  membrane  unaffected,  but,  on  the  contrary,  acts  upon  this  mem- 
brane and  destroys  it ;  and  whenever  the  mucous  membrane  lining  a 
stricture  is  destroyed  there  is  a  grave  probability  that  the  urethra  will 
be  obliterated. 

It  is  probable  in  many  cases  in  which  some  surgeons  have  claimed 
beneficial  results  from  electrolysis  that  this  agent  did  not  exert  its  pecu- 


218  STRICTURE  OF  THE   URETHRA. 

liar  decomposing  power,  but  simply  acted  as  a  stimulant,  which  may 
have,  aided  by  other  measures,  tended  to  cause  the  absorption  of  some 
soft  stricture  tissue. 

Within  recent  years  attention  has  been  called  to  the  favorable 
results  obtained  by  Fort's  electrolyser  in  the  class  of  cases  for  which 
Maisonneuve's  operation  is  indicated.  The  electrolyser  resembles  in 
a  general  way  Maisonneuve's  urethrotome  when  the  filiform  guide  has 
been  attached  and  the  knife  has  been  pushed  down  the  grooved  staff. 
It  really  consists  of  two  nearly  equal  parts,  the  distal  one  being  the 
filiform  guide  and  the  proximal  one  being  a  fine,  soft  bougie  (calibre 
about  6  or  8  French  scale),  through  the  whole  length  of  which  there  is 
a  thin,  metallic  wire.  This  wire,  just  before  the  junction  of  the  prox- 
imal with  the  flexible  distal  portion,  is  bent  so  as  to  form  an  obtuse 
conical  projection,  which  resembles  the  blade  of  Maisonneuve's  instru- 
ment. This  platinum  blade,  therefore,  is  the  active  agent  in  the  oper- 
ation. The  filiform  guide  is  passed  down  the  urethra  until  the  elec- 
trolytic blade  (as  we  may  call  it)  rests  on  the  face  of  the  stricture.  The 
instrument  is  then  connected  with  the  negative  pole  of  a  continuous 
current  battery  and  the  positive  pole,  which  is  flat  and  of  the  size  of 
one's  palm,  is  placed  near  the  penis,  either  on  a  thigh  or  on  the  lower 
part  of  the  abdomen.  The  current  is  then  turned  on.  This  should  be, 
in  general,  of  a  strength  of  ten  milliamperes,  as  shown  by  an  attached 
galvanometer.  During  the  operation,  the  electrolytic  blade  remains 
cool,  and  is  gently  pushed  downward  by  the  surgeon,  and  in  many  cases 
traverses  the  strictured  tissue  in  less  than  a  minute  ;  but  in  very  firm, 
dense,  and  quite  long  strictures,  two  or  three  minutes  may  elapse  before 
the  operation  is  complete.  In  cases  in  which  there  are  several  strictures 
seated  at  a  distance  from  each  other,  more  time  is  consumed.  Haste, 
however,  is  not  at  all  essential  in  these  cases ;  indeed,  it  seems  that  a 
more  lasting  effect  is  produced  if  the  blade  is  allowed  to  traverse  the 
tissues  very  slowly.  In  this  way,  in  all  probability,  a  more  potential 
action  is  produced.  In  all  cases,  copious  irrigations  with  warm  boric 
solutions  should  be  used,  both  before  and  after  the  operation.  On  the 
withdrawal  of  the  instrument,  the  evidence  of  the  electrolytic  action  is 
seen  in  the  little  mass  of  disintegrated,  perhaps  slightly  effervescent, 
tissue  which  comes  away  with  it.  In  general,  it  may  be  stated  that  the 
operation  is  nearly  painless  ;  some  patients  make  an  outcry  from  fear, 
while  others  complain  of  a  slight  stabbing  sensation.  There  may  be  no 
hemorrhage  at  all,  or  the  flow  of  blood  may  be  slight ;  it  never  is  suf- 
ficient to  cause  any  uneasiness. 

The  electrolyser  is  useful,  in  that  it  decomposes  a  segment  of  the 
stenosed  urethral  canal,  and  then  by  destruction  of  tissue,  gives  more 
relief  than  the  thin  incision  of  Maisonneuve's  blade,  and  it  does  this 
with  precision.     Added  to  this,  there  need  be  no  septic  complications. 


TREATMENT  OF  RETENTION.  219 

In  eases  of  very  long  firm  strictures  and  those  in  which  the  lesion 
consists  of  copious  modular  masses,  it  will  be  frequently  found  that  the 
electrolyser  will  fail  to  traverse  them. 

Urethrectomy. — This  operation  may  be  employed  in  some  severe 
cases  of  traumatic  and  modular  stricture,  which  cannot  be  cured  by 
external  urethrotomy.  In  some  cases  the  stricture  mass  is  excised  and 
the  cut  ends  of  the  urethra  are  approximated  and  sutured,  this  coapta- 
tion being  impossible  it  may  be  necessary  to  pass  and  retain  a  catheter 
and  allow  the  wound  to  cicatrize.  In  this  event  recontraction  almost 
inevitably  occurs. 

After  resection  of  the  damaged  urethra  the  attempt  may  be  made  to 
restore  it  by  means  of  the  transplantation  of  mucous  membrane  and  the 
formation  of  a  partially  new  canal.  Up  to  the  present  time  this  oper- 
ation has  not  been  followed  by  conspicuously  good  results. 

Retention  of  Urine. — In  the  declining  stage  of  acute  gonorrhoea, 
usually  as  the  result  of  alcoholic  excesses,  catching  cold,  great  exertion, 
and  perhaps  of  sexual  excesses,  retention  of  urine  may  occur  due  to 
great  swelling  of  the  urethral  mucous  membrane  and  of  spasm  of  the 
compressor  urethras  muscle.  In  some  cases  of  gonorrhceal  congestion 
of  the  prostate  the  lumen  of  the  urethra  is  so  compressed  that  urinary 
retention  occurs.  This  condition  may  also  follow  operations  on  the 
perineum,  testes,  cord,  rectum,  and  anus. 

In  cases  of  stricture  of  the  urethra  owing  to  cold,  various  excesses, 
and  perhaps  to  rough  and  unskilful  instrumentation,  retention  of  urine 
may  be  produced.  In  the  treatment  of  retention  due  to  gonorrhoea, 
after  thoroughly  cleansing  the  glans  penis  the  surgeon  should  take  a 
well-lubricated  No.  18  or  20  F.  flexible  blunt  or  olivary  catheter  and 
slowly  pass  it  toward  the  bladder.  If  at  the  bulb  or  posterior  to  it  he 
meets  an  obstruction,  he  should  not  use  violence  and  he  should  not  be 
in  a  hurry.  Gently  pressing  the  end  of  the  catheter  against  the  obstruc- 
tion, he  holds  it  there  and  waits,  and  usually  in  a  few  minutes  it  will 
slowly  pass  into  the  bladder.  If  this  is  not  accomplished  at  once,  the 
patient  may  be  placed  in  a  hot  bath,  and  ten  or  fifteen  drops  of  laudanum 
well  diluted  in  water  may  be  given  to  him.  As  a  rule,  this  course  will 
be  followed  by  the  passage  of  the  catheter  and  the  patient's  relief.  In 
these  cases  the  posterior  urethra  is  in  all  probability  invaded,  and  the 
urethral  trouble  will  not  be  materially  made  worse  even  if  it  is  neces- 
sary to  pass  the  catheter  several  times.  In  all  cases  irrigations  with 
hot  boric  solution  may  be  used  in  the  bladder  and  urethra,  and  by  them 
the  inflammation  may  be  checked. 

In  older  subjects  retention  usually  results  from  urethral  stricture. 
Having  ascertained  the  patient's  history,  the  surgeon  passes  to  the  face 
of  the  obstruction  a  flexible  gum-elastic  catheter  about  20  F.     By  this 


220 


STRICTURE  OF  THE   URETHRA. 


Fro.  59. 


he  can  gain  knowledge  of  the  nature  of  the  obstruction.  If  a  narrow 
stricture  is  present,  it  is  well  to  try  to  get  through  with  the  English 
styletted  catheters  of  very  small   size,  which  have  such   stability  that 

they  will  frequently  pass  where 
Ftg.  60.  tbe  French  ones  foil. 

Thompson's  retention  cath- 
eter, when  skilfully  handled, 
sometimes  produces  brilliant 
results  in  the  relief  of  retention. 
(See  Fig.  59.)  Unskilfully  used, 
it  is  a  dangerous  instrument. 
Bumstead's  retention  catheter, 
which  has  a  French  filiform  flex- 
ible guide,  may  be  kept  ready 
for  use,  since  by  it  the  surgeon 
may  sometimes  reach  the  blad- 
der when  he  has  almost  begun 
to  despair.  (See  Fig.  60.)  For 
the  use  of  filiforms  in  retention 
due  to  stricture  the  reader  is 
referred  to  the  section  thereon. 
(Seep.  189.)  Having  traversed 
the  stricture  with  the  filiform, 
it  can  be  the  means  of  guiding 
a  small  Gouley  tunnelled  cathe- 
ter into  the  bladder,  by  which 
the  urine  may  be  drawn  off. 
(See  Fig.  61.) 

At  this  time,  if  expedient, 
external  urethrotomy  may  be 
performed,  or  the  stricture  may 
be  dilated  by  the  successive  in- 
troduction of  tunnelled  sounds 
of  increasing  calibre.  In  cases 
of  stricture  retention  it  is  often 
beneficial  to  employ  hot  baths, 
hot  rectal  injections,  and  suppos- 
itories of  opium  and  belladonna. 
Aspiration. — In  very  ur- 
gent cases  of  retention  of  urine 
from  stricture,  particularly  in  middle-aged  and  elderly  men,  or  of  pros- 
tatic hypertrophy  in  which  the  surgeon  fails  to  reach  the  bladder  with  a 
catheter,  it  may  be  necessary  to  draw  off  the  urine  by  means  of  suprapubic 


Thompson's  retention 
catheter,  with  mal- 
leable silver  probe- 
point. 


Bumstead's  retention  cath- 
eter, with  screw-point  so 
that  it  may  be  attached  to 
any  filiform  bougie  em- 
ployed with  incision  in- 
struments. 


TREATMENT  OF  RETENTION.  221 

aspiration.     (See  Fig.  62.)      For  this  purpose  Hayden's  aspirator  is  a 
simple  and  ideal  instrument. 

Fig.  61. 


Tunnelled  catheter  staff,  showing  the  conductor  in  the  terminal  canal  and  the  stylet  a  little 

withdrawn. 

Fig.  62. 


Hayden's  aspirator  and  trocar. 

In  performing  aspiration  it  is  important  that  the  pubes  should  be 
shaved  and  rendered  surgically  clean.  Then  the  instrument  should 
be  tested  before  use,  and  it  should  be  made  certain  that  the  needle  is 
pervious.  It  is  then  sterilized.  The  area  of  operation  is  about  one 
inch  above  the  upper  margin  of  the  symphysis  pubis,  and  at  most  one 
inch  on  each  side  of  the  median  line.  In  this  restricted  field,  if  proper 
care  and  caution  are  exercised,  many  punctures  may  be  made,  and  by 
them  sufficient  time  may  be  gained  to  allow  the  urethra  and  prostate  to 
lose  much  of  their  engorgement  and  to  permit  the  passage  of  catheters. 
In  many  cases  as  many  as  four  punctures  of  the  bladder  daily  for  six 
and  eight  days  may  be  made  with  local  benefit  and  without  any  untoward 
symptom  whatever.  After  the  withdrawal  of  the  urine  a  small  quan- 
tity of  warm  boric  solution  may  be  injected  into  the  bladder. 

On  the  withdrawal  of  the  aspirating  needle  suction  should  be  kept 
up  until  its  point  is  well  out  of  the  wound.  Otherwise,  some  of  the 
urine  (and  it  is  usually  of  septic  character)  may  escape  into  the  cellular 
tissues  and  produce  an  abscess. 

In  very  rare  cases  the  upward  growth  of  the  prostate  is  such  that  it 
shuts  off  the  bladder  from  approach  above  the  pubes,  in  which  event  the 
aspirating  needle  cannot  reach  the  vesical  cavity. 

The  points  of  puncture  may  be  painted  with  iodoformized  collodion. 

It  is  necessary  here  to  warn  the  operator  not  to  fully  empty  the 
bladder  in  elderlv  and  old  men  who  are  suffering  from  retention  due 
either  to  stricture  or  prostatic  hypertrophy.  At  the  first  attempt  at 
relief  if  the  bladder  is  very  full  and  protuberant,  about  a  pint  of  urine 
may  be  drawn  off,  and  before  the  catheter  is  withdrawn  half  a  pint  of 
warm  boric-acid  solution  should  be  injected  into  the  bladder.     When  the 


222  STRICTURE   OF  THE   URETHRA. 

distressing  symptoms  are  again  felt,  a  similar  withdrawal  and  an  injec- 
tion should  be  made.  In  this  way  in  the  course  of  twenty-four  or 
thirty-six  hours  the  patient  can  be  much  relieved.  In  old  stricture  and 
prostatic  cases  there  is  always  a  certain  amount  of  residual  urine  ;  conse- 
quently it  is  the  surgeon's  duty  to  ascertain  its  quantity,  and  always 
after  the  final  catheterism  for  relief  of  retention  to  leave  a  similar  amount 
of  boric-acid  solution  in  the  bladder.  Failure  to  carry  out  this  cautious 
and  slow  method  of  catheterism  may  result  in  serious  bladder  and  kidney 
lesions,  and  perhaps  in  death.  When  all  urine  is  suddenly  drawn  from 
the  bladder  in  those  cases  where  there  has  been  more  or  less  intense 
vesical,  urethral,  and  kidney  congestion,  the  vessels  at  first  become  sud- 
denly exsanguinated  ;  then,  when  the  circulation  is  re-established,  hem- 
orrhage occurs  into  the  kidneys  and  bladder,  and  death  ensues. 

Extravasation  of  Ueixe. — As  a  result  of  violent  straining  efforts 
in  some  cases  of  very  tight  strictures  the  urethral  walls,  which  have 
become  thinned  and  abnormally  weak,  give  way,  and  the  urine  then 
gushes  into  the  surrounding  connective  tissue.  This  is  the  sudden  and 
more  common  form  of  extravasation.  In  contradistinction  to  it  there 
is  a  slow  or  gradual  form  of  the  accident,  which  begins  in  a  limited 
manner  as  a  small  abscess,  probably  of  follicular  origin,  which  slowly 
increases  until  an  opening  is  tunnelled  by  which  the  urine  may  slowly 
or  gradually  escape  into  the  surrounding  tissues.  In  this  latter  event 
the  escaping  urine  may  become  walled  in  by  inflammatory  exudation, 
and  a  hard  or  fluctuating  lump  may  be  felt  usually  in  the  perineum. 

Rupture  of  the  urethra  may  occur  (1)  in  the  course  of  the  penis  as 
far  back  as  the  anterior  layer  of  the  triangular  ligament.  It  may  rupt- 
ure (2)  in  its  membranous  portion,  between  the  layers  of  the  triangular 
ligament,  and  (3)  behind  the  triangular  ligament,  either  at  the  junction 
of  the  membranous  and  prostatic  urethra  or  in  the  pix>static  urethra 
itself.  The  direction  of  the  extravasation  varies  according  to  the  part 
of  the  urethra  which  is  the  seat  of  rupture. 

Rupture  of  the  pendulous  urethra,  which  is  rather  rare  and  due 
either  to  stricture  or  impacted  calculus,  causes  much  swelling  of  the 
organ.  The  fibrous  covering  investing  the  corpus  spongiosum,  which 
consists  of  fascia  derived  from  the  suspensory  ligament  of  the  penis  and 
from  the  deep  perineal  fascia,  may  remain  intact,  and  then  the  swelling 
pushes  down  to  the  root  of  the  penis  and  the  scrotum  ;  or  this  fibrous 
investment  may  be  ruptured,  in  which  case  there  is  much  extravasation  into 
the  connective  tissue  of  the  penis  itself  and  also  into  the  scrotal  tissues. 

AVhen  rupture  takes  place  just  anterior  to  the  triangular  ligament, 
the  urine  is  prevented  by  this  dense  stricture  from  escaping  into  the 
pelvic  cavity.  It  cannot  diffuse  itself  down  the  thighs,  because  the 
deep  perineal  fascia  is  firmly  adherent  to  the  ischiopubic  line ;   conse- 


EXTRAVASATION  OF  URINE.  223 

quently,  it  takes  the  easy  course  and  ascends  up  the  hypogastrium 
between  the  pubic  spine  and  the  symphysis.  The  extravasation  may 
in  severe  cases  reach  as  far  up  as  the  umbilicus. 

Extravasations  between  the  two  layers  of  the  triangular  ligament 
in  the  membranous  urethra  may  be  due  to  stricture,  traumatism,  im- 
pacted calculus,  and  careless  urethrotomy.  In  these  cases  suppuration 
and  sloughing  are  prone  to  occur  more  or  less  promptly.  The  urine 
forms  for  itself  a  sinus  usually  anteriorly  and  sometimes  directed  back- 
ward. In  the  first  case  the  morbid  swelling  shows  itself  in  the  peri- 
neum and  scrotum,  and  in  the  second  in  the  pelvis,  where  it  may  be 
detected  as  a  boggy  mass  by  means  of  the  finger  in  the  rectum.  Extrav- 
asation in  the  prostatic  urethra  may  result  from  operations  on  the  pros- 
tate urethra,  fracture  of  the  pelvis,  impacted  calculus,  and  stricture 
anterior  to  this  region. 

When  the  extravasation  occurs  behind  the  posterior  layer  of  the  trian- 
gular ligament,  the  urine  may  gush  or  leak  out  down  the  rectovesical 
space  and  points  in  the  perineum  anterior  to  or  at  the  sides  of  the  anus  ; 
or  it  may  ascend  through  the  pelvic  fascia  near  the  puboprostatic  liga- 
ment, and  then  diffuse  itself  through  the  prevesical  space.  In  these 
cases  much  information  may  be  obtained  by  digital  examination  of  the 
rectum,  by  which  doughy  swellings  around  and  to  the  sides  of  the  pros- 
tate and  in  the  rectovesical  space  may  be  made  out. 

The  symptoms  of  extravasation  of  urine  are  generally  well  marked. 
Extravasations  anterior  to  the  triangular  ligament  usually  present  such 
marked  features  that  they  are  promptly  recognized.  The  symptoms  of 
rupture  into  the  membranous  urethra  may  at  first  be  mild,  but  they 
grow  worse  as  the  urine  tunnels  for  itself  a  passage  and  allows  of 
copious  extravasation. 

Extravasations  behind  the  triangular  ligament  may  be  attended  by 
marked  symptoms  when  the  gush  of  urine  is  prompt  and  copious.  In 
some  cases,  however,  the  extravasation  takes  place  quite  slowly,  and 
then  the  symptoms  may  not  be  well  marked  and  are  not  appreciated  for 
a  day  or  more. 

Usually  a  patient  suffering  from  extravasation  states  that  he  felt 
something  give  way,  and  experienced  a  sensation  of  relief,  but  he 
wonders  why  his  urine  does  not  flow  away  normally.  Very  soon 
systemic  symptoms  set  in.  The  patient  complains  of  great  weakness 
and  depression,  nausea,  fever,  and  perhaps  chills.  Then  it  is  noticed 
that  the  scrotum  is  more  or  less,  even  enormously,  distended,  and  that 
the  swelling  extends  up  to  the  hypogastrium,  perhaps  to  the  umbilical 
region,  or  laterally  in  the  iliac  region.  The  skin  then  becomes  tense  and 
erysipelatous,  and  to  the  finger-tips  gives  the  sensation  of  emphysema- 
tous crackling.     The  bright-red  hue  rapidly  becomes  dusky,  purplish, 


224  STRICTURE  OF  THE   URETHRA. 

and  even  gangrenous.     Sloughs  of  skin  may  come  away,  and  in  some  cases 
the  whole  scrotum  is  destroyed,  leaving  the  testicles  bare. 

Unless  relieved  by  operation,  patients  suffering  from  extravasation 
go  on  from  bad  to  worse.  Nausea,  vomiting,  total  anorexia,  mild  de- 
lirium, high  fever,  and  a  small  wiry  pulse  are  the  chief  symptoms.  The 
patient  becomes  more  feeble,  and  has  a  dry,  parched  tongue,  his  mut- 
tering delirium  increases,  and  he  perishes  in  coma  from  uraemia  and 
septicaemia. 

It  is  very  probable  that  the  condition  of  the  urine  has  much  to  do 
with  the  course  and  gravity  of  extravasation.  If  this  fluid  is  in  an 
aseptic  condition,  it  is  much  less  destructive  (and  it  is  claimed  by  some 
not  at  all  destructive)  to  the  tissues.  Consequently,  necrosis  and  its 
concomitant,  septicaemia,  may  not  occur,  particularly  if  prompt  relief  is 
given  by  the  knife.  Unfortunately,  in  the  majority  of  cases  in  which 
the  urethra  is  the  seat  of  tight  stricture,  the  walls  behind  it  are  much 
damaged  and  the  bladder  is  deeply  affected.  The  urine,  as  a  result,  is 
largely  mixed  with  pus,  and  is  poisonous  to  tissues  with  which  it  may 
come  in  contact. 

Treatment. — It  is  most  important  in  all  cases  of  extravasation  to 
perform  external  urethrotomy  promptly  (see  pp.  212,  et  seq.),  and 
introduce  a  perineal  tube,  and  irrigate  and  drain  the  bladder.  When 
the  penis  is  much  swollen,  several  longitudinal  incisions  (about  2  or  3 
inches  long)  should  be  made  well  down  in  the  connective  tissues.  Then 
all  sloughs  should  be  carefully  removed,  and  the  parts  should  be  freely 
and  constantly  irrigated  with  hot  sublimate  solution  1  :  5000,  and  hot 
saline  solutions.  In  like  manner,  if  necessary,  deep  incisions  should 
be  made  into  the  scrotum,  the  perineum,  or  the  anterior  abdominal 
walls,  and  the  wounds  should  be  aseptically  treated,  care  being  taken 
that  all  sloughs  and  gangrenous  tissue  are  removed  and  the  parts 
rendered  as  clean  as  possible.  In  most  cases  much  benefit  will  follow 
the  careful  squeezing  and  pressing  of  the  tissues  by  the  finger-tips,  by 
which  means  morbid  secretions  may  be  removed. 

In  the  rather  rare  event  of  extravasation  into  the  prevesical  space 
it  will  be  necessary  to  make  a  free  suprapubic  incision  through  the 
anterior  abdominal  wall  in  order  to  irrigate  the  parts  thoroughly  and 
frequently  and  drain  them.  All  these  wounds  must  be  carefully  packed 
with  iodoform  or  sterile  gauze,  which  should  be  held  in  place  by  layers 
of  sterilized  cotton  and  gauze  and  a  retention-bandage.  It  is  very 
important  that  the  dressings  of  these  patients  shall  be  carefully  watched 
and  frequently  renewed,  and  that  their  beds  shall  be  kept  in  a  state  of 
cleanliness.  By  means  of  great  care  and  attention  the  fetid  and 
ammoniacal  discharge  may  soon  disappear,  and  the  sloughs  will  sepa- 
rate and  leave  a  healthy  surface. 


URETHRAL   FEVER,    OR    URINARY  INFECTION.  225 

We  are  generally  called  upon  to  sustain  the  sinking  powers  of  life  by 
the  free  exhibition  of  nourishment  and  stimulants,  such  as  beef-tea, 
brandy,  milk-punch,  carbonate  of  ammonia,  quinine,  strychnine,  etc. 
Opium  is  of  much  value  when  there  is  much  pain  or  nervous  irritability. 

In  cases  of  shock  it  may  be  well  to  inject  hot  normal  salt  solution 
into  the  median  basilic  vein,  or  into  the  rectum,  or  subcutaneously. 

Urethral  Fever,  or  Urinary  Infection. 

Following  operations  upon  the  urethra  and  bladder  for  stricture, 
cystitis,  vesical  neoplasms,  calculus,  retention,  and  prostatic  hyper- 
trophy, particularly  in  chronic  cases  of  young  men,  in  men  approach- 
ing middle  age,  and  in  old  men,  certain  febrile  disturbances  of  mild  or 
severe  character,  and  septic  infectious  conditions  are  sometimes  observed, 
which  have  been  variously  called  urethral  fever,  urinary  fever,  catheter 
fever,  urinary  poisoning,  and  urinary  ^infection. 

After  such  simple  operations  on  the  urethra  as  the  gentle  passage  of 
a  bougie  or  catheter,  incision  of  the  meatus,  and  even  the  introduction 
of  the  meatus  sound,  some  patients  become  faint,  pale,  and  may  lose 
consciousness.  This  condition  is  simply  a  mild  form  of  shock,  and  is 
analogous  to  the  fainting  spells  following  blows  on  the  testes  or  cord  or 
the  subcutaneous  ligature  of  the  spermatic  veins.  In  some  cases  these 
symptoms  are  mild  and  very  ephemeral,  while  in  others  they  are  more 
severe  and  prolonged.  Though  these  conditions  are  generally  con- 
sidered under  the  head  of  urinary  fever,  they  are  in  no  sense  related  to 
that  condition.     They  are  simply  the  evidence  of  reflex  nervous  action. 

After  instrumental  operation  on  the  urethra  patients  may  have  a 
slight  rise  in  temperature,  preceded  or  perhaps  followed  by  a  chill,  which 
passes  oif  and  does  not  recur.  This  condition  may  be  observed  in  some 
cases  with  the  passage  of  the  first  urine  after  urethrotomy,  tight  cath- 
eterization, or  divulsion.  This  condition  represents  the  mild  and  ephem- 
eral form  of  urethral  fever.     In  it  the  patient  is  only  mildly  sick. 

The  second  form  is  that  which  is  called  "  acute  urethral  fever,"  in 
which  the  chill  is  severe  and  often  prolonged,  the  rise  in  temperature 
sudden  (104°  to  106°  Fahr.,  and  even  beyond  this),  and  in  which  the 
systemic  symptoms  are  correspondingly  severe.  In  some  cases  defer- 
vescence is  ushered  in  with  sweats.  This  condition  may  last  one  or 
several  days,  and  it  may  recur  at  intervals.  The  patient  is  usually  a 
quite  sick  man. 

This  second  form  may  cease  or  it  may  become  chronic,  and  it  is  then 
called  "  chronic  urinary  fever."  This  is  mostly  observed  in  elderly  and 
old  men  suffering  from  stricture,  and  its  pathological  sequences  in  the 
membranous  and  prostatic  urethra,  bladder,  and  perhaps  kidney,  and 
also  in  cases  of  prostatic  hypertrophy,  calculus,  and  vesical  neoplasms. 

15 


226  STRICTURE  OF  THE   URETHRA. 

The  fever  is  of  a  mild  type,  perhaps  continuous,  and  again  it  may  be 
intermittent.  During  its  course  irregular  slight  chills  or  severe  rigors 
may  be  experienced.  This  condition  is  indicative  of  grave  trouble  of 
the  whole  urinary  tract,  and  it  tends  to  undermine  the  patient's  health. 
Persons  thus  affected  lose  flesh,  become  sallow,  suffer  severely  from  dys- 
pepsia, and  gradually  lose  ground,  until  they  die  either  from  uraemia 'or 
septicaemia. 

In  most  of  the  very  severe  cases  there  is  suppression  of  urine. 

Urinary  infection  with  fulminating  lethal  symptoms  has  sometimes 
been  observed.  In  a  classical  case  in  medical  literature  a  man  broken 
in  health  and  suffering  from  tight  stricture,  who  was  catheterized  with- 
out violence,  pain,  or  bleeding,  was  seized  immediately  after  the  opera- 
tion with  a  severe  rigor,  passed  into  syncope,  and  died  in  a  few  min- 
utes. In  another  classical  case  the  stricture  in  the  pendulous  urethra 
was  long  and  tight.  It  had  been  mildly  dilated,  and  six  and  a  half  hours 
after  the  passage  of  a  small  sound  the  man  suddenly  collapsed  and  died. 

The  underlying  primary  cause  of  urinary  fever  is  some  inflammatory 
focus  in  the  urethra  and  bladder.  When  this  condition  is  well  marked 
and  chronic,  and  the  urethra  and  bladder  are  decidedly  affected  and  the 
urine  is  septic,  then  the  patient  is  liable  to  urinary  infection.  If  the 
pathological  changes  are  as  yet  not  far  advanced,  the  results  of  instru- 
mental manipulation  in  disturbing  them  are  mild  and  show  themselves 
by  the  ephemeral  form  of  fever.  When  the  changes  are  more  chronic 
and  deep-seated,  the  tissues  react  more  violently  and  the  fever  is  more 
severe. 

In  the  grave  order  of  cases  there  is  always  coexisting  renal  impair- 
ment. Now,  on  this  pathological  basis  as  a  result  of  damage,  even  mild, 
done  in  operation,  certain  microbes  seem  to  luxuriate,  and  they  secrete 
the  poison  which  gives  rise  to  the  inflammatory  and  septic  phenomena 
already  described.  An  attentive  reading  of  the  results  of  the  various 
investigators  seems  to  show  that  the  chief  morbific  agent  in  urinary 
poisoning  is  the  bacterium  coli  commune.  We  cannot  say  definitely 
where  this  microbe  breeds  and  has  its  being — whether  it  is  in  the 
affected  tissues  or  in  the  urine,  probably  in  the  latter,  and  perhaps  in 
both.  It  seems  certain  that  without  tissue-disturbance  and  trauma  this 
micro-organism  may  remain  dormant,  but  that  when  the  condition 
of  the  tissues  has  become  altered  by  loss  of  epithelium  and  other 
unknown  states,  it  becomes  hostile  and  produces  urinary  poisoning. 

In  many  patients  this  microbe  seems  to  hibernate,  and  does  not 
become  pathogenic  even  when  there  is  much  tissue  damage  (they  seem 
in  a  measure  immune  to  its  action),  while  in  others  the  slightest  trauma 
seems  to  be  the  starting-point  of  its  virulence  and  its  wildfire-like  spread. 
Perhaps  in  some  patients  the  vitality  of  the  microbe  is  weak,  and  it  is 


URETHRAL  FEVER,    OR    URINARY  INFECTION.  227 

imperfect  in  its  development.  It  is  a  significant  fact  that  in  all  very 
grave  cases  there  is  more  or  less  presumptive  or  conclusive  evidence  of 
renal  derangement.  The  urethral  and  vesical  disturbances  then  seem 
(how  we  cannot  exactly  say)  to  react  promptly  on  the  kidneys,  and  as  a 
result  we  have  the  mixed  conditions  of  urinary  infection  and  of  uraemia, 
and  more  or  less,  even  total,  suppression  of  urine. 

While  we  can  thus  speak  with  considerable  certainty  as  to  the  pres- 
ence, nature,  and  pathological  action  of  the  bacterium  coli  commune,  we 
are  as  yet  in  the  dark  as  to  the  role  of  the  pathological  action  of  the 
pyogenic  microbes  which  are  also  found  in  pathological  urine  and  in  the 
genito-urinary  tract. 

The  practical  lesson  to  be  learned  from  all  these  researches  is  to  do  as 
little  violence  to  urethral  and  vesical  tissues  as  possible,  and  to  be  thor- 
ough in  the  matter  of  asepsis  and  antisepsis.  It  can  be  readily  seen 
that  drugs  taken  internally  cannot  efficiently  act  upon  the  morbid  con- 
ditions of  the  tissues  or  on  the  microbes  and  their  poisons  contained  in 
the  urine. 

Treatment. — The  essential  point  in  the  treatment  of  all  cases  of 
lesions  of  the  urethra,  prostate,  and  bladder  is  to  be  so  thorough  in  the 
matter  of  antisepsis  that  urinary  infection  will  not  occur.  To  this  end 
all  operations  on  these  parts  should  be  attended  with  much  care  in  the 
matter  of  thorough  drainage,  and  frequent  and  copious  irrigations  with 
hot  saturated  boric  or  bichloride  solutions,  1  :  5000,  should  be  made.  - 

The  ephemeral  chills  and  fever  sometimes  observed  may  require  little 
or  no  treatment  beyond  rest  in  bed,  diluent  drinks,  with  perhaps  salol, 
quinine,  and  opium.  In  all  these  cases  instrumentation  or  operation  in 
the  urethra  or  bladder  should  be  accompanied  with  careful  antiseptic 
irrigation.  This  applies  to  operations  for  stricture,  and  on  the  prostate 
and  the  bladder.  In  cases  of  chronic  cystitis  and  hypertrophy  of  the 
prostate,  in  which  fever  is  observed,  the  frequent  and  careful  with- 
drawal of  the  urine  by  means  of  a  sterilized  catheter,  and  the  thorough 
irrigation  of  the  urethra  and  bladder  with  antiseptic  solutions,  are  abso- 
lutely necessary.  In  many  cases  of  prostatic  hypertrophy  the  occur- 
rence of  fever  may  be  avoided  by  the  judicious  use  of  the  catheter, 
which  prevents  the  damage  to  the  prostate  and  urethra  that  sometimes 
occur  in  the  straining  incident  to  urination.  In  some  of  these  cases 
the  avoidance  of  the  passage  of  the  urine  over  the  urethra,  which  is 
obtained  by  the  use  of  the  catheter,  undoubtedly  tends  to  prevent  or 
lessen  the  tendency  to  local  infection  and  its  resulting  fever.  When  the 
kidneys  are  coincidentally  involved  and  the  urine  is  albuminous  and 
bloody,  and  in  cases  where  suppression  of  urine  occurs,  it  is  necessary 
to  resort  promptly  to  hot-air  baths  and  to  cups  over  the  kidneys,  and  to 
administer  internally  tincture  of  digitalis,  sweet  spirits  of  nitre,  and 
diuretin,  and  to  give  the  patient  plenty  of  pure  water  to  drink. 


228  STRICTURE   OF  THE    URETHRA. 

When  there  is  tendency  to  shock  and  syncope,  hot  normal  salt  solu- 
tion may  be  injected  into  the  median  basilic  vein,  or  subcutaneously,  or 
into  the  rectum. 


Stricture  of  the  Urethra  in  the  Female. 

This  is  a  rather  rare  affection  and  is  usually  the  result  of  traumatism 
during  child-birth,  of  chronic  gonorrhoea,  of  cicatrization  of  chan- 
croidal or  syphilitic  ulcers,  and  perhaps  it  may  be  due  to  urethral  cal- 
culus and  to  damage  of  the  parts  sustained  in  the  removal  of  vesical 
calculi,  caruncles,  and  neoplasms.  The  parts  usually  involved  are  the 
internal  vesical  orifice  and  the  tissues  at  and  near  the  meatus,  the 
middle  portion  of  the  canal  generally  being  unaffected.  These  strict- 
ures are  formed  of  dense  fibrous  tissue  whose  tendency  is  to  contract 
gradually  and  lessen  the  calibre  of  the  canal,  until  in  some  instances  it 
is  scarcely  pervious. 

The  symptoms  are  well  marked  in  proportion  to  the  development  of 
the  stricture.  As  the  lumen  of  the  urethra  becomes  smaller,  the  diffi- 
culty in  urination  increases  until  it  may  in  the  end  be  almost  wholly 
retarded.  In  women  as  in  men  with  urethral  stricture,  more  or  less 
complete  retention  may  result  from  exposure  to  cold,  fatigue,  and  to 
alcoholic  and  sexual  excesses. 

It  is  rare  to  observe  vesical  and  renal  complications  in  women  as 
the  result  of  stricture. 

Diagnosis. — The  diagnosis  of  urethral  stricture  in  women  is  usually 
very  easy.  In  some  cases  a  nodular  condition  of  the  canal  may  be 
made  out  by  the  finger-tip  in  the  vagina  pressed  against  the  lower  wall 
of  the  urethra.  When  the  stricture  is  very  small  and  tight,  it  may  only 
be  possible  to  pass  a  probe  through  it  into  the  bladder.  In  other  cases 
olivary  bougies  of  various  size  may  be  tried,  until  one  is  passed  by 
which  the  calibre  of  the  stricture  may  be  determined. 

Treatment. — In  all  cases  it  is  necessary  after  careful  antisepsis  to 
make  a  free  incision  on  the  upper  and  lower  wall  of  the  urethra,  and 
then  to  pass  every  few  days  a  full-sized  meatus-sound  in  the  same 
manner  as  is  done  in  the  male. 

In  some  cases  the  stricture  may  be  so  small  that  it  is  necessary  to 
incise  it  with  a  Gouley's  beaked  bistoury,  while  in  others  the  straight 
blunt  bistoury  will  work  well. 

In  some  cases  prompt  relief  of  the  stricture  may  follow  urethrotomy 
performed  with  the  Maisonneuve-Fluhrer  instrument.  If  in  these  cases 
the  bladder  has  become  affected,  it  will  be  necessary  to  use  hot  boric 
irrigations  followed  by  dilute  nitrate-of-silver  solutions  and  suitable 
internal  medication. 


CHAPTER   XI. 

AFFECTIONS  OF  THE  PENIS. 
PHIMOSIS. 

Phimosis  is  that  condition  of  the  prepuce  which  prevents  its  retrac- 
tion and  the  exposure  of  the  glans.     It  may  be  congenital  or  acquired. 

Congenital  Phimosis. 

The  morbid  structural  conditions  giving  rise  to  congenital  phimosis 
are — first,  the  narrowing,  sometimes  entire  occlusion,  of  the  preputial 
orifice  ;  second,  a  straightness  and  narrowness  of  the  prepuce  itself;  and 
third,  shortness  of  the  frsenum.  To  these  may  be  added,  in  the  acquired 
form,  redundance  of  the  prepuce.  The  orifice  of  the  prepuce  may  be 
as  small  as  a  pin's  head,  when  it  may  offer  an  impediment  to  urination 
and  prevent  inspection  of  the  meatus, 

and  as  large  as  the  diameter  of  a  IG'      ' 

pea.  (See  Fig.  63.)  Not  infrequently 

patients  who  have  not  suffered  from  ^iiPfe 

phimosis  in  their  youth  do  so  later, 
owing  to  the  growth  of  the  glans 
penis  and  to  the  concomitant  imper- 
fect development  of  the  prepuce. 

In  most  cases  of  congenital  phi- 
mosis there  are  adhesions  between 
the  mucous  membrane  and  the  glans. 
These  may  be  thin,  small,  but  nu- 
merous and  easily  broken  up,  or  they 
may  be  extensive  and  firm,  even  to 
the  complete  adherence  of  the  whole 
prepuce  and  the  glans.  >>J? 

Congenita]  phimosis  gives  rise  to  ^^^^^ 

balanitis,  heat,  itching,  even  pain, 

.       .        ..      „  .  Congenital  phimosis  in  the  infant. 

in  the  head  of  the  penis,  and  a  con- 
sequent erethism  of  the  genitals,  with  frequent  erections,  symptoms 
pointing  to  stone  in  the  bladder,  lascivious  dreams,  seminal  emissions, 
and  incontinence  of  urine,  especially  at  night.  Such  subjects  are  often 
addicted  to  masturbation.  As  they  grow  older  there  is  in  many  an 
arrest  of  development  of  the  penis.     When  puberty  is  reached  any  or 

229 


230 


AFFECTIONS  OF  THE  PENIS. 


all  of  the  foregoing  symptoms  may  exist,  and  such  subjects  often  com- 
plain of  too  speedy  ejaculations  and  a  not  satisfactory  and  complete 
enjoyment  of  sexual  intercourse. 

In  early  life,  as  remote  effects  of  phimosis,  it  has  been  conclusively 
shown  that  nervous  disturbances,  incoordination  of  the  muscles  of  loco- 
motion and  of  speech,  hyperesthesia,  amblyopia,  and  hypochondriasis 
have  been  produced. 

It  must  be  remembered,  however,  that  there  are  many  cases  of  phi- 
mosis which  are  not  attended  by  any  of  the  foregoing  symptoms,  direct 
or  remote.  At  puberty  and  later,  however,  phimosis  always  gives  rise 
to  unpleasant  symptoms  of  varying  degrees  of  severity,  such  as  balanitis 
and  interference  with  erections  and  the  sexual  act.  At  this  period,  par- 
ticularly, it  is  a  prolific  cause  of  masturbation  and  of  a  morbid  desire 
for  coitus. 

In  some  cases  of  congenital  phimosis  plates  and  masses  of  smegma 
form  under   the  prepuce,  which  is  bulged  out  by  them.      Sometimes 

these  smegma-masses  are  so 
firm  in  structure  that  they 
are    mistaken     for     calculi. 
/  /,  J^  They  may  remain  in  an  in- 

dolent condition  for  years, 
and  may  give  rise  to  no  symp- 
toms. 


Fig.  65. 


Fig.  64. 


Smallness  of  preputial  orifice,  with  fibroid  frsenum. 

Chronic  Inflammatory  Phimosis. 

There  is  a  condition  of  the  penis  in  which  patients  suffer  much  dis- 
comfort until  relieved  by  operation.  It  is  admirably  shown  in  Figs.  64 
and  65.  This  condition  consists  in  smallness  of  the  preputial  orifice, 
smallness  as  to  calibre,  and  shortness  of  the  prepuce,  together  with  a 
short  fibrous  frsenum.  In  these  cases  all  the  unpleasant  symptoms  of 
phimosis  are  present,  and  a  chronic  rebellious  balanitis  is  an  important 


ACQUIRED  PHIMOSIS. 


231 


factor.     Usually,  in  such  cases,  the  glans  remains  stunted  and  small 
in  circumference  and  length,  as  is  well  shown  in  the  figure. 

The  morbid  process  in  phimosis  of  all  forms  may  be  simply  inflam- 
matory oedema,  or  this  condition  plus  simple  or  specific  cell-infiltration. 


Acquired  Phimosis. 

Acquired  or  accidental  phimosis  may  exist  in  a  prepuce  normally 
rather  small,  but  capable  of  thorough  retraction,  or  in  one  which  in  the 
normal  state  passes  readily  backward  and  forward  over  the  glans.  The 
causes  of  it  are  want  of  cleanliness,  the  decomposition  of  diabetic  urine, 
excessive  venery,  perhaps  increased  by  the  abuse  of  stimulants,  gonor- 
rhoea, herpes  preputialis,  eczema,  chancroids,  and  hard  chancres.  Trau- 
matism and  compression  of  tightly-fitting  pantaloons  are  also  causes. 


Fig.  66. 


Fig.  67. 


Gonorrhceal  phimosis. 


Phimosis  with  the  pouting  chin. 


The  symptoms  vary  in  severity  and  in  the  nature  of  their  concomitants 
according  to  the  cause. 

Phimosis  resulting  from  uncleanliness  and  excessive  venery  presents 
nothing  characteristic.  The  prepuce  is  red  and  inflamed,  and  there  is 
more  or  less  balanitis.  It  is  usually  an  ephemeral  trouble  and  readily 
amenable  to  local  remedies. 


232  AFFECTIONS  OF  THE  PENIS. 

Gonorrheal  Phimosis. 

Phimosis  complicating  gonorrhoea  is  often  a  troublesome  concomitant, 
since  it  interferes  so  much  with  the  treatment  of  that  affection.  There 
are  commonly  much  redness  and  swelling,  which  often  produce  curious 
deformities  of  the  organ,  as  shown  in  Fig.  66,  in  which  the  prepuce  is 
much  swollen.  In  some  cases  the  penis  is  curved  upward,  in  others 
downward,  and  sometimes  laterally.  Sometimes  the  intensity  of  the 
inflammation  is  seated  in  the  prepuce  near  the  frsenum,  which  becomes 
swollen  and  turned  inward,  giving  the  appearance  of  a  pouting  chin. 
(See  Fig.  67.)  Then,  again,  the  whole  extent  of  the  foreskin  may  be 
involved,  in  which  case  the  distal  end  of  the  penis  becomes  greatly 
swollen  and  comes  to  resemble  a  miniature  Indian  club.  In  all  of  these 
cases  there  is  a  purulent  urethral  discharge.  Phimosis  caused  by  herpes 
progenitalis  presents  redness  and  oedema  of  the  distal  end  of  the 
penis,  together  with  vesicles. 

Gangrene  is  a  rather  uncommon  complication  of  the  simple  forms  of 
inflammatory  phimosis,  excepting  when  due  to  traumatism  and  diabetes. 
It  is  not  very  rare  in  the  severer  forms. 

Cicatricial  Phimosis. 

Cicatricial  nhimosis  belongs  to  the  category  of  the  acquired  affec- 
tions.    Cicatrices  frequently  follow  fissures  and  ulceration  which  have 

„      „n  been   produced   by  forcible   retraction. 

Fig.  68.  L  .  ... 

gr     :  ^        ;  A  fibroid  preputial  ring  is  not  uncom- 

%    I  I  monly  seen  in  cases  of  phimotic  pre- 

puce. Chronic  balanitis  also,  in  some 
cases  of  long  and  somewhat  phimotic 
prepuce,  causes  a  condition  of  cicatriza- 
tion of  its  outer  preputial  layer  which 
much  intensifies  the  phimosis.  Such 
is  the  stenosis  of  the  preputial  orifice 
in  some  of  these  cases  that  circumcision 
alone  will  relieve  the  patients  of  their 
discomfort  and  suffering.  Recurrent 
herpes  preputialis  may  cause  stenosis 
of  the  orifice,  either  from  scars  or  in- 
filtration. It  is  somewhat  remarkable 
mXxm.A  ■      +         t.  -,  „  -fi  that  in  some  cases  of  phimosis,  where 

Fibroid  ring  at  preputial  orifice.  r 

retraction  has  been  impossible  through- 
out life,  little  if  any  suffering  has  been  produced.  In  Fig.  68  is 
shown  a  phimotic  prepuce  with  a  firm  fibrous  ring  at  the  orifice,  the 
development  of  twenty-five  years.     In  this  case  there  was  no  suffering 


PHIMOSIS  FROM  INTRAPEEPUTIAL  LESIONS.  233 

or  discomfort,  and  the  development  of  the  fibroid  tissue  was  so  aphleg- 
masic  that  it  was  not  appreciable  to  the  patient. 

From  puberty  to  old  age  recurrent  balanitis,  even  in  persons  having 
roomy  foreskins  and  of  cleanly  habits,  sometimes  leads  to  increase  and 
induration  of  the  subpreputial  connective  tissue,  and  converts  that 
appendage  into  a  rather  resistant,  inextensible  cylinder,  which  is  with 
difficulty  retracted.  In  some  cases  the  subpreputial  connective  tissue 
is  converted  into  flat,  firm  plates  of  tissue,  which  prevent  retraction 
and  favor  inflammation. 

Phimosis  from  Obesity. 

In  elderly  men,  as  they  advance  in  age  and  obesity,  the  integument 
of  the  penis  often  becomes  redundant  and  lax.  As  time  goes  on,  the 
prepuce  becomes  much  elongated  and  extends  well  down  beyond  the  end 
of  the  glans.  The  organ  then,  in  many  cases,  becomes  a  source  of  dis- 
comfort. The  inner  layer  of  the  prepuce  becomes  hypersemic,  and  the 
urine  and  smegma  readily  decompose  and  cause  irritation,  with  burning 
sensations. 

Phimosis  from  Intrapreputial  Lesions. 

The  initial  lesion  of  syphilis,  when  seated  on  the  inner  leaf  of  the 
prepuce  at  the  frsenum  and  in  the  sulcus,  very  frequently  in  the  lower 
classes  produces  phimosis,  caused  usually  by  want  of  care  and  unclean- 
liness.  The  distal  portion  of  the  penis  becomes  much  swollen,  and  in 
typical  cases  the  inflammation  is  of  a  low  grade.  Then  the  organ  at 
the  preputial  portion  is  of  a  deep  bluish-red,  not  hot  or  painful.  In 
some  cases  the  induration  may  be  made  out  by  palpation,  but  usually 
as  the  phimosis  develops  the  sclerotic  mass  or  nodule  is  so  masked  by  the 
surrounding  oedema  that  it  cannot  be  recognized.  Usually  the  condi- 
tion remains  rather  aphlegmasic.  The  indurated  tissues  continue  to 
have  the  bluish-red  color,  without  heat  or  pain,  and  the  condition  is 
further  complicated  with  typical  enlargement  of  the  inguinal  ganglia. 
In  some  cases  pus,  and  in  others  seropus,  escapes  from  the  preputial 
orifice. 

In  other  cases,  however,  the  initial  lesion  under  the  prepuce  in  phi- 
mosis becomes  inflamed,  and  then  the  condition  resembles  chancroidal 
phimosis.  In  many  of  these  cases  chancroids  form  at  the  free  end  of 
the  prepuce,  and  a  mistake  in  diagnosis  is  then  very  liable  to  be  made. 
In  such  cases  the  history  and  the  condition  of  the  inguinal  ganglia  may 
afford  aid  in  the  recognition  of  the  real  condition  of  affairs.  Chronic 
indurating  oedema,  complicating  chancres,  and  secondary  lesions,  may 
cause  phimosis. 


'  234  AFFECTIONS  OF  THE  PENIS. 

Treatment. — In  all  cases  of  congenital  phimosis  circumcision  should 
be  performed  at  as  early  an  age  as  possible.  Efforts  made  to  expand 
the  preputial  orifice  in  young  children  are  usually  painful  and  produce 
only  a  partial  and  temporary  relief. 

In  cases  of  inflammatory  phimosis  the  patient  should  assume  the 
recumbent  position  and  should  partake  of  a  light  diet.  The  preputial 
cavity  in  the  height  of  the  inflammation  should  be  well  irrigated  several 
times  a  day  with  very  warm  lead-water,  and  in  the  intervals  the  penis 
may  be  well  wrapped  with  absorbent  gauze,  which  is  saturated  with  the 
same  lotion.  In  a  few  days  bichloride  irrigations,  1  :2000,  may  be 
employed. 

As  soon  as  retraction  of  the  prepuce  is  possible,  lint  or  old  linen  or 
absorbent  cotton  soaked  in  lead-and-opium  wash  must  be  placed  between 
it  and  the  glans,  and  treatment  followed  as  given  in  the  section  on 
Balanitis. 

Phimosis  from  gonorrhoea  needs  active  and  continuous  treatment,  in 
addition  to  that  of  the  acute  stage  of  the  discharge.  Intrapreputial 
irrigations,  very  hot,  frequently  made,  and  large  in  quantity,  of  bichlor- 
ide solution  1  to  2000  or  3000,  or  of  a  saturated  boric-acid  solution,  or 
of  a  1  per  cent,  carbolic  solution,  should  be  employed.  The  penis 
should  be  kept  in  an  elevated  position ;  care  must  be  taken  to  catch  and 
remove  the  discharge. 

THE    OPERATION    OF    CIRCUMCISION. 

Circumcision  should  be  performed  as  soon  as  possible  in  cases  of 
chronic  phimosis,  cicatricial  phimosis,  and  phimosis  complicated  by 
intrapreputial  vegetations. 

In  performing  the  operation  of  circumcision  it  is  necessary  to 
remember  that  the  prepuce  is  composed  of  two  layers,  separated  by 
a  cellular  tissue  of  such  lax  texture  as  to  admit  of  an  almost  indefinite 
amount  of  motion  between  them.  The  internal  or  mucous  layer  is 
firmly  attached  to  the  penis  posterior  to  the  corona  glandis,  and  hence 
is  incapable  of  being  drawn  forward  to  any  great  extent  in  front  of 
the  glans.  The  external  or  integumental  layer,  on  the  contrary,  is  con- 
tinuous with  the  flaccid  skin  of  the  body  of  the  penis,  and  may  be 
greatly  elongated. 

Previous  to  the  operation  of  circumcision  the  penis  should  be  care- 
fully examined  by  the  surgeon  with  a  view  of  acquainting  himself  with 
the  conformation  of  the  parts  and  of  determining  the  amount  of  tissue 
to  be  taken  away.  If  retraction  of  the  prepuce  is  possible,  it  is  import- 
ant to  study  the  size,  shape,  and  relations  of  the  fraenum,  and  the  calibre 
of  the  cutaneous  sheath  at  the  part  where  it  encircles  the  glans.  Then 
it  is  necessary  to  inspect  the  raphe  closely,  in  order  to  see  whether  it 


THE  OPERATION  OF  CIRCUMCISION. 


235 


runs  directly  in  the  median  line,  or  whether  it  deviates,  as  it  sometimes 
does,  to  one  side  or  the  other  toward  the  end  of  the  prepuce. 

I  prefer  the  following  operation  for  its  simplicity  and  excellency  of 
results.  The  patient  having  been  prepared  and  placed  on  the  operating- 
table,  the  prepuce  is  drawn  well  forward,  and  the  clamp  or  forceps  (Fig. 
69)  is  applied,  not  in   a  vertical  direction  at  right  angles  with   the  long 

Fig.  69. 


Author's  circumcision  forceps  or  clamp. 

axis  of  the  penis,  but  in  an  oblique  position,  following  the  line  of  ob- 
liquity of  the  glans.  When  the  clamp  is  on,  it  is  necessary  to  examine 
the  skin  of  the  penis  to  see  that  too  much  of  the  tissues  will  not  be  taken 
away,  and  that  the  organ  in  erection  will  not  be  interfered  with  or 
drawn  backward.  While  the  clamp  is  adjusted,  cocaine  auaesthesia  may 
be  produced  by  the  following  simple  procedure  :  A  syringe  being  filled 
with  8  per  cent,  muriate-of-cocaine  solution,  its  needle,  an  inch  and  a 
half  long,  is  introduced  between  the  two  layers  of  the  prepuce  on  one 
side  obliquely,  in  conformity  with  the  blades  of  the  forceps.  When 
the  needle  has  traversed  the  whole  of  one  side  of  the  included  prepuce, 
a  few  drops  of  the  cocaine  solution  are  injected,  and  as  the  needle  is 
slowly  withdrawn,  the  fluid  is  left  in  its  track.  Then  the  same  proced- 
ure is  followed  on  the  other  side  of  the  prepuce.  The  parts  are  then 
left  alone  for  a  few  minutes,  in  order  that  anaesthesia  may  be  produced. 
After  the  lapse  of  about  five  minutes  the  blades  of  the  forceps  are 
slightly  separated,  and  thus  kept  for  a  few  minutes,  in  which  time  the 
immediate  tissue  behind  the  forceps  blades  will  become  anaesthetized. 
Then  the  clamp  is  again  put  on  firmly.  By  this  procedure  we  avoid 
the  unpleasant,  even  dangerous,  symptoms  of  cocaine  intoxication  and 
poisoning.  Traction  on  the  distal  end  of  the  prepuce  by  a  ligature  or 
forceps  is  now  made,  and  a  straight  bistoury  is  introduced  through  the 
middle  of  the  prepuce,  the  flat  of  the  blade  resting  on  the  clamp.  An 
outward  cut  is  then  made,  and  a  second  inward  cut  removes  the  cutane- 
ous layer  of  the  prepuce.  Some  cocaine  solution  is  now  poured  over 
the  bleeding  surface.  The  surgeon  then  retracts  the  mucous  layer  of 
the  prepuce,  and  ascertains  its  length  and  the  condition  of  the  fraenum. 
The  parts  having  become  anaesthetized,  a  ligature  is  run  through  the 
mucous  layer,  and  traction  is  made  by  it,  and  the  forceps  is  applied  in 
the  same  oblique  manner  to  this  part.  The  second  incision  is  then 
made  in  precisely  the  same  manner  as  the  first  was.     It  is  generally 


236  AFFECTIONS  OF  THE  PENIS. 

necessary  to  crowd  the  glans  backward  somewhat,  but  the  surgeon 
should  always  make  allowance  that  one-third  or  one-half  of  an  inch  of 
the  mucous  layer  of  the  prepuce  shall  be  left,  and  that  as  much  of  the 
frsenum  shall  be  spared.  When  too  much  of  the  mucous  layer  is  taken 
away,  and  when  the  frsenum  is  nearly,  if  not  all,  ablated,  a  bad  result 
is  always  obtained,  and  the  patient  may  experience  much  discomfort  for 
the  rest  of  his  life.  The  incised  mucous  and  cutaneous  layers  are  then 
coapted,  and  before  the  sutures  are  put  in  the  surgeon  should  study  the 
conformation  of  the  parts  with  a  view  to  future  symmetry.  In  general, 
the  raphe  and  the  frsenum  are  in  distinct  anatomical  continuation,  and 
then  the  surgeon  in  his  suturing  simply  follows  these  natural  land- 
marks. If,  however,  there  is  a  deviation  of  the  raphe  from  the  middle 
line,  this  must  be  considered,  and  the  line  of  union  so  placed  that  a 
natural  arrangement  of  the  parts  will  be  produced  after  healing.  There 
is  usually  more  or  less  hemorrhage,  but  this  very  rarely  gives  any 
trouble.  When  the  edges  are  properly  coapted  the  sutures  of  fine  silk 
or  catgut  should  be  put  in  at  a  distance  of  a  sixth  of  an  inch  from  the 
margin  of  the  wound,  well  through  the  whole  thickness  of  the  skin  and 
mucous  membrane.  These  sutures  should  be  placed  about  one-sixth  or 
one-eighth  of  an  inch  apart,  so  that  no  connective  tissue  will  be  exposed 
between  the  cut  edges.  By  these  quite  numerous  sutures  all  bleeding 
is  prevented  and  prompt  healing  is  produced.  "Whenever  the  sutures 
are  placed  far  apart,  the  raw  submucous  connective  tissue  pushes  up 
between  the  two  cut  surfaces,  and  the  process  of  healing  is  materially 
prolonged.  The  parts  are  then  dusted  with  iodoform  or  aristol,  and 
well  and  sufficiently  firmly  bandaged  with  absorbent  gauze.  The  first 
dressing  mav,  owing  to  oozing,  have  to  be  removed  on  the  third  or 
fourth  day,  and  then  replaced  by  a  similar  one.  If  the  dressing  looks 
clean  and  the  patient  is  comfortable  (there  being  no  itching,  smarting, 
or  uneasiness  in  the  penis),  the  first  dressing  may  remain  on  several 
days.  When  thorough  antisepsis  is  practised,  perfect  union  may  result 
in  a  few  days,  particularly  if  the  patient  can  remain  in  the  recumbent 
position  and  if  medication  to  prevent  erections  has  been  administered. 
Erections  sometimes  materially  delay  union.  The  sutures  may  then  be 
removed,  and  a  dressing  applied  for  a  few  days.  Usually  two  or  three 
dressings  are  sufficient.  After  the  operation  the  parts  may  be  more  or 
less  sensitive  for  a  time,  but  they  gradually  adapt  themselves  to  their 
altered  condition. 

In  some  cases  of  urgency  it  may  be  necessary  to  perform  circumcis- 
ion, and  the  proper  instruments  may  not  be  at  hand.  In  this  event  the 
following  simple  operation  may  be  performed  :  The  parts  being  prop- 
erly cleansed  and  shaved,  the  prepuce  is  drawn  forward  (if  retraetible) 
over  the  glans  ;  then,  by  means  of  a  pair  of  scissors  with  long  blades, 


PARAPHIMOSIS.  237 

an  incision  is  made  in  the  middle  line  on  the  dorsum  of  the  penis.  The 
prepuce  then  appears  like  two  dog's  ears,  which  must  be  cut  off  with 
the  scissors,  following  the  line  of  obliquity  of  the  glans.  In  this  oper- 
ation it  is  necessary  to  be  careful  that  the  two  incisions  of  the  dog's 
ears  are  symmetrical,  that  too  much  tissue  is  not  taken  away,  and  that 
the  framum  is  left  intact.  The  parts  are  then  sutured,  the  same  care 
being  taken  as  has  already  been  pointed  out.  The  dressing  is  the  same 
as  that  of  the  first  operation. 

PARAPHIMOSIS. 

Paraphimosis  is  that  condition  in  which  the  prepuce,  retracted  behind 
the  corona,  cannot  be  pushed  forward  over  the  glans. 

It  is  found  in  young  boys  who,  perhaps  from  curiosity  and  with  some 
force,  have  retracted  the  prepuce  for  the  first  time.  It  also  occurs  in 
young  subjects  as  a  result  of  masturbation.  In  these  cases  the  young 
boy  usually  complains  of  pain  quite  early,  and  reduction  is  commonly 
not  attended  with  difficulty. 

Paraphimosis  occurs  in  older  persons  who-  have  a  long  foreskin  and 
narrow  preputial  orifice ;  in  those  who  have  a  long,  straight,  and  more 
or  less  tight  foreskin  ;  in  patients  who  have  a  short  frsenum ;  in  those 
who  have  short  and  rather  tight  foreskins  habitually  worn  over,  and 
only  partially  covering,  the  glans  ;  in  those  having  short,  not  abundant, 
foreskins  worn  behind  the  glans ;  and,  finally,  in  those  whose  foreskin 
is  in  perfect  proportion  to  the  glans. 

Causes. — The  causes  of  paraphimosis  are,  primarily,  the  more  or 
less  developed  malformations  ;  secondly,  inflammation  causing  constric- 
tion, balanitis,  excessive  coitus,  perhaps  increased  by  alcoholic  excess ; 
coitus  with  a  woman  having  a  small  vulvar  orifice  ;  traumatism,  gonor- 
rhoea, eczema,  lymphangitis  ;  the  retraction  of  a  phimotic  prepuce  the 
seat  of  intrapreputial  vegetations  ;  chancroids  and  hard  chancres.  It 
is  seen  in  all  grades  of  mildness,  in  which  it  is  reducible,  and  in  all 
stages  of  severity,  in  which  reduction  is  more  or  less  difficult  and  even 
impossible  without  operation  or  incision. 

The  mechanism  of  paraphimosis  is  very  simple.  Retraction  of  the 
tight  preputial  orifice  behind  the  glans  leaves  a  fold  or  ring  of  mucous 
membrane  just  behind  and  continuous  with  it,  and  which  ceases  at  a 
more  or  less  deep  furrow,  and  beyond  this  furrow  is  a  swollen  ring  or 
fold  of  integument.  The  ring  of  mucous  membrane  is  the  inner  surface 
of  the  prepuce  ;  the  furrow  is  formed  by  the  orifice  of  the  prepuce,  at 
the  bottom  of  which  it  acts  as  a  constricting  ring,  while  the  cutaneous 
fold  or  ring  beyond  is  the  external  layer  of  the  prepuce.  In  this  con- 
dition inflammation  begins  and  increases.  The  glans  becomes  swollen 
and  red,  even  purplish,  in  color ;  the  mucous  collar  of  the  penis  becomes 


238 


AFFECTIONS  OF  THE  PENIS. 


red,  (edematous,  and  puffed  out  like  a  bladder ;  the  constricting  preputial 

ring  strangulates  the  parts  more  and  more  as  they  become  swollen ;  and 

the  cutaneous  ring  or  collar  beyond 
Pig.  70.  -ii  , 

it  also  becomes  more  red  and  cede- 

,v\     ,"(.„' .  ,  matous.     In  such  a  case,  if  relief 

•', ";,  ^   \  is  not  obtained,  the  condition  of 

affairs  becomes  worse.  Besides  the 
engorged  glans,  the  chief  swelling 
is  seated  under  and  just  behind  it 
on  each  side  of  the  frsenum.  When 
seen  quite  early  this  chin-like  pro- 
trusion of  mucous  membrane  is 
found  to  be  filled  with  serous  effu- 
sion. (See  Fig.  70.)  As  time 
goes  on,  this  is  replaced  by  fibrin- 
ous and  cellular  exudation,  and 
this  chin-like  body  becomes  hard 
and  resisting.  Coincidently  with 
this  the  strangulation  of  the  glans 
is  greater ;  the  mucous-membrane 
pad  behind  it  is  more  red,  swollen, 
and  infiltrated ;  the  constricting 
ring  is  correspondingly  smaller; 
the  cutaneous  ring  of  prepuce  behind  it  more  swollen.  In  this  state 
the  penis  often  becomes  twisted  in  spiral  and  other  peculiar  forms, 
curved  nearly  at  a  right  angle,  and  sometimes  distended  to  the  point 
of  strangulation  (Fig.  71).  In  conditions  thus  seemingly  desperate 
the  parts  may  remain,  and  become  permanently  fixed  by  cell-exuda- 
tion. Generally,  however,  nature  intervenes,  if  art  is  withheld,  and 
the  constricting  ring  is  attacked  by  ulceration  or  gangrene  ;  in  which 
case  a  longitudinal  fissure  forms  along  the  dorsum  in  the  mucous  layer 
of  the  prepuce,  and  a  corresponding  one  in  the  cutaneous  portion. 
These  increase,  fuse,  involve  the  preputial  ring,  and  end  by  forming  an 
ulcer  seated  transversely  to  the  axis  of  the  penis  and  behind  the  glans. 
Constriction  is  then  ended,  the  patient's  sufferings  are  relieved,  but 
much  oedema  and  engorgement  may  remain. 

In  somewhat  exceptional  and  anomalous  cases  there  are  two  points 
of  strangulation — the  one  at  the  preputial  orifice  or  ring,  the  other  in 
the  mucous  membrane  at  the  base  of  the  corona  gland  is,  and  largely 
due  to  the  excessive  engorgement  of  the  part.  Then  in  other  cases  the 
retraction  of  the  prepuce  is  incomplete,  and  the  orifice  or  ring  only 
slips  back  behind,  and  not  much  beyond,  the  corona,  where  it  is  firmly 
held,  and  is  with  difficulty  reduced  except  by  operation. 


Acute  reducible  paraphimosis,  with  profuse 
serous  effusion. 


PARAPHIMOSIS. 


239 


Gangrene,  however,  may  occur  under  these  circumstances  and  may 
result  in  the  destruction  of  more  or  less  of  the  integument  or  odans, 
may  involve  the  urethra,  may  perforate  a  blood-vessel,  cause  intense 
suppurative  inflammation,  and  lead  to  lymphangitis.     (See  Fig.  71.) 


Fig.  71. 


Paraphimosis  with  gangrene. 

In  the  paraphimosis  due  to  the  initial  lesion  the  parts  are  hard  and 
brawny,  and  the  process  is  of  a  subacute  nature.  In  the  paraphimosis 
complicating  chancroids  we  have  the  simple  condition  plus  much  ulcera- 
tion, inflammation,  and  swelling.  In  these  latter  cases,  if  not  treated 
promptly,  there  may  be  destruction  of  tissue  of  greater  or  less  extent. 
There  may  therefore  be  resulting  deformity  in  these  severe  forms  of 
paraphimosis. 

Prognosis. — The  prognosis  of  paraphimosis  depends  entirely  upon 
the  stage  of  the  trouble  when  first  seen.  If  the  surgeon  is  consulted 
early,  reduction  can  be  accomplished  without  difficulty,     If  later,  when 


240 


AFFECTIONS  OF  THE  PEXIS. 


strangulation  has  taken  place,  various  sequela?,  from  the  dorsal  ulcer  or 
gangrenous  spot  to  more  extended  gangrene  and  destruction  of  the 
integument  and  perhaps  portions  of  the  glans  and  urethra,  may 
occur. 

Treatment. — The  first  procedure  necessary  in  a  case  of  paraphimosis 
is  to  wash  the  penis  thoroughly  with  soap  and  water,  and  after  drying 
the  parts  to  irrigate  them  thoroughly  with  warm  bichloride  solution, 
1  :  2000.  Then  the  parts  having  been  cocainized,  reduction  should  be 
attempted,  and  in  case  of  its  failure  an  operation  is  necessary.  Previous 
to  attempting  reduction  a  little  olive  oil  or  vaseline  may  be  smeared  in 


Fig. 


Paraphimosis  :  penis  curved  nearly 


the  balanopreputial  furrow,  but  not  on  the  glans,  since  it  then  causes  the 
operator's  fingers  to  slip. 

It  should  be  clearly  borne  in  mind  that  in  those  cases  in  which  the 
mucous  membrane  of  the  region  of  the  framum  is  translucent  and  much 
serum  is  seen  (see  Fig.  70),  multiple  punctures,  followed  by  gentle 
pressure  by  the  hand  around  the  head  of  the  penis,  will  always  be 
followed  by  benefit  and  the  prompt  reduction  of  the  parts. 

Several  methods  of  reduction  may  be  employed.  A  simple  plan  is 
to  make  a  ring  of  the  forefinger  and  thumb  of  the  left  hand,  which 
firmly  encircles  the  penis  behind  the  constriction ;  at  the  same  time 
that  this  hand  is  drawn  forward,  the  glans,  grasped  by  the  fingers  of 
the  right  hand,  and  at  the  same  time  compressed  and  elongated,  is 
pushed  backward,  and  reduction  may  follow.  Another  method  is  to 
take  the  penis  behind  the  constriction  between  the  index-  and  middle- 


PARAPHIMOSIS. 


241 


fingers  of  both  hands,  and,  making  very  firm  traction  while  the  thumbs 
crowd  down  upon  it,  knead  and  press  the  dorsum  and  base  of  the  glans 
backward.     (See  Fig.  73.) 

In  many  cases  incision  of  the  constricting  band  is  sufficient  to  relieve 
the  parts.  Since  in  most  cases  this  is  seated  in  the  furrows  already 
described,  a  curved  bistoury  may  be  introduced  on  the  flat  surface  on 
the  glandular  side  of  the  constriction,  well  down  under  and  through  it, 
taking  care  not  to  wound  the  corpora  cavernosa.  If  the  swelling  is  such 
that  the  curved  bistoury  cannot  be  introduced  beneath  the  band,  a 
straight  one  may  be  used.  This  should  be  introduced  at  right  angles  to 
the  penis  at  the  outer  edge  of  the  constriction,  and  a  number  of  firm  but 

Fig.  73. 


Method  of  reduction  of  paraphimosis. 

not  deep  cuts  should  be  made,  the  operator  being  slow  and  deliberate 
in  his  movements  with  the  point  of  the  instrument  until  the  band  is 
felt  to  give  way. 

In  some  cases  it  is  necessary  to  incise  the  mucous  membrane  and  skin 
in  the  line  with  the  incisions  already  spoken  of.  When  this  is  done,  it 
is  well  to  inquire  as  to  the  natural  length  of  the  prepuce,  and  to  make 
the  incisions  in  conformity  with  the  facts  ascertained.  Another  rule  is 
to  take  the  length  of  the  glans  as  the  guide,  and  make  the  incision  as 
long  as  that.  As  a  result  of  this  procedure  the  patient  subsequently 
has  the  so-called  dog's-ear  prepuce,  which  requires  a  further  operation 
to  complete  the  circumcision. 

When  the  constriction  exists  just  behind  the  glans,  it  is  sometimes 
with  difficulty  made  out,  and  much  care  must  be  observed  to  cut  it 
alone. 

1G 


242  AFFECTIONS  OF  THE  PENIS. 

Cases  of  chronic  paraphimosis  in  which  cicatricial  adhesion  has 
taken  place  require  long  and  patient  treatment.  The  parts  should  be 
soaked  in  hot  water  two  or  three  times  a  day,  and  then  the  segment 
behind  the  glans  may  be  compressed  for  several  hours  a  day  by  a  rubber 
bandage.  When  absorption  has  gone  on  to  such  an  extent  that  move- 
ment, even  slight,  of  the  prepuce  over  the  corpora  cavernosa  is  possible, 
it  is  well  to  free  the  cutaneous  ring-like  end  of  the  prepuce  and  the 
mucous  end  of  it,  which  are  at  the  constricting  furrow,  either  by  gentle 
dissection  or  by  tearing  apart  with  a  blunt  instrument.  Then,  when 
these  parts  are  loosened,  a  longitudinal  incision  of  nearly  or  possibly  an 
inch  long  is  made  into  each  of  these  segments  of  the  prepuce.  Then, 
after  one  or  more  attempts,  reduction  will  usually  follow  and  the  typical 
dog's  ears  will  be  seen.  The  case  then  requires  cleanliness,  and  later 
on  ablation  of  the  lateral  portions  of  the  prepuce. 

BALANITIS. 

The  term  balanitis  may  be  applied  to  inflammation  of  the  mucous 
membrane  of  the  glans,  or  of  the  prepuce,  or  to  both  conditions 
combined. 

Simple  Forms. 

This  affection  is  most  commonly  seen  in  persons  having  some  abnor- 
mality of  the  prepuce,  such  as  smallness  of  its  orifice,  straightness, 
tightness,  and  redundancy,  and  shortness  of  the  frsenum.  It  is  also 
seen  in  persons  having  a  normal  penis  and  in  those  whose  prepuce  is 
very  short.  In  most  cases  it  shows  a  tendency  to  relapse,  and  one 
attack  predisposes  toward  subsequent  ones.  It  exists  in  an  acute  and  a 
chronic  form,  and  in  all  degrees  from  mild  to  very  severe.  The  symp- 
toms vary  according  to  the  severity  of  the  case.  In  some  there  is  a 
moderate  itching  sensation ;  in  others,  a  burning  pain  of  various 
degrees. 

In  its  most  simple  form  balanitis  presents  a  very  red,  somewhat 
thickened  surface,  covered  with  a  milky  secretion  emitting  a  penetrat- 
ing and  offensive  odor.     This  condition  is  very  amenable  to  treatment. 

Balanitis  in  a  more  advanced  form  presents  well-marked  features. 
The  glans  and  prepuce  are  swollen,  and  when  the  latter  is  retracted  a 
mottled  surface  of  shining  whiteness,  broken  by  deep-red  superficial 
and  irregular  excoriations,  is  seen.  In  this  case  in  some  parts  the 
epithelium  still  remains,  and,  having  been  macerated  by  the  secretions, 
presents  the  whitish-pearly  look  spoken  of,  while  in  other  parts  it  is 
cast  off,  and  as  a  result  the  red  excoriated  patches  are  left. 

In  other  cases  upon  retracting  the  prepuce  it  is  found  that  the  glans 
or  its  covering,  or  both,  are  the  seat  of  redness  and  swelling,  and  that 


CHRONIC  BALANITIS.  243 

their  surface  is  covered  with  minute,  closely-packed  vesicles,  which  rup- 
ture promptly  and  give  rise  to  excoriations. 

The  foregoing,  which  we  may  call  the  simple  forms  of  balanitis,  may 
be  promptly  cured  by  appropriate  treatment.  But  should,  for  any 
reason,  the  irritating  cause  persist,  a  more  severe  form  of  the  affection 
results.  With  the  increase  of  the  redness  and  swelling  the  excoriations 
give  rise  to  exulceration,  which  may  be  superficial  and  covered  with 
thin,  soft,  greenish  crusts,  and  which  is  called  "  exulcerated  balanitis." 
Under  unfavorable  circumstances  these  superficial  lesions  of  continuity 
may  become  transformed  into  deeper  ulcers,  very  often  indistinguish- 
able from  chancroids. 

Simple  balanitis  sometimes  assumes  a  very  severe  form,  particularly 
in  uncleanly  persons  and  in  those  who  have  been  in  temperately  treated 
by  caustic  applications.  The  penis,  particularly  at  the  glans,  becomes 
very  much  swollen,  very  red,  and  perhaps  the  seat  of  ulceration.  In 
some  cases  the  whole  penis  is  involved.  In  this  stage  the  affection  may 
be  mistaken  for  cancer. 

Chronic  Balanitis. 

In  contradistinction  to  the  foregoing  acute  forms  of  balanitis  there 
is  the  chronic  form.  In  general,  chronic  balanitis  is  seen  in  persons 
beyond  thirty  years  of  age.  It  begins  upon  the  glans  and  prepuce, 
which  are  usually  in  close  coaptation,  owing  to  some  abnormality. 
The  inflammation  is  usually  of  a  subacute  character,  and  shows  decided 
exacerbations  and  remissions.  In  this  way  the  affection  extends  over 
years.  If  retraction  of  the  prepuce  is  more  or  less  possible,  a  some- 
what reddened,  thickened,  and  perhaps  slightly  excoriated,  surface  is 
revealed.  Owing  to  the  thickness  and  lessened  elasticity  of  the  pre- 
puce, it  rolls  back,  if  at  all,  with  difficulty,  and  in  many  instances  this 
procedure  is  wholly  prevented  by  the  development  of  a  fibroid  ring  at 
the  preputial  orifice.  Such  patients  say  that  they  have  constant  incon- 
venience with  their  penis,  have  much  difficulty  in  cleansing  the  foreskin 
and  glans,  and  have  recurrences  of  tolerably  mild  inflammation.  When 
examined  from  time  to  time  a  decided  thickening  of  the  epithelium  is 
seen,  together  with  considerable  increase  in  the  submucous  connective 
tissue.  The  parts  then  have  a  bluish-white,  milky-looking  surface, 
which  rarely  becomes  frankly  red,  owing  to  the  fact  that  the  blood- 
vessels have  been  narrowed  by  the  general  condensation  of  the  mucous 
membrane.  To  the  touch  such  a  glans  and  foreskin  feel  firm,  some- 
what like  wash-leather,  and,  as  time  goes  on,  turgescence  of  the  end 
of  the  penis  is  never  complete.  Unless  in  such  a  case  circumcision  is 
performed,  the  growth  of  the  epithelial  covering  of  the  glans  increases 
and  much  diminishes  its  size,  and  very  frequently  it  so  compresses  it 


244  AFFECTIONS  OF  THE  PENIS. 

that  it  levels  the  corona  until  it  is  continuous  in  line  with  the 
fossa. 

Not  only  are  these  cases  distressing  in  the  discomfort  and  suffering 
incident  to  the  progress  of  the  affection,  but  they  are  also  attended  with 
much  gravity,  since  as  years  increase  there  is  a  decided  tendency  for 
them  to  undergo  malignant  degeneration. 

Causes. — In  most  cases  balanitis  is  due  to  uncleanliness,  and  results 
from  the  decomposition  of  the  epithelial  matter  which  is  formed  in  the 
crypts  seated  in  the  mucous  layer  of  the  prepuce.  Excess  in  coitus, 
coitus  with  a  woman  with  a  small  vulvar  orifice  or  with  one  suffering 
from  leucorrhoea,  and  masturbation,  are  frequent  causes.  The  existence 
of  vegetations  under  the  prepuce  is  a  frequent  cause  of  balanitis,  and 
the  lodgement  of  gonorrheal  pus  in  that  position  also  causes  it.  In 
some  cases  the  gonorrhoeal  discharge  excites  inflammation  at  the  pre- 
putial orifice,  which  extends  to  the  prepuce  and  glans.  Chancroidal 
pus  and  the  secretions  of  primary  and  secondary  syphilitic  lesions,  and 
these  lesions  themselves,  are  also  prolific  causes  of  balanitis. 

Micro-organisms  play  an  important  part  in  the  development  of 
balanitis. 

Diabetic  Balanitis. 

In  rare  cases  balanitis  may  complicate  diabetes.  The  subjective 
symptoms  of  this  form  are  quite  similar  to,  but  more  intense  than, 
those  of  ordinary  balanitis.  The  patients  complain  of  severe,  even 
atrocious,  itching  and  burning  sensations,  comparable  to  those  of 
pruritus  vulvae,  and  the  mucous  membrane  looks  edematous,  and  of 
a  color  midway  between  red  and  violet.  A  profuse  purulent  secretion 
is  constantly  seen,  together  with  flakes  or  masses  of  smegma  and  micro- 
organisms which  look  like  croupous  exudation.  The  surface  of  the 
glans  and  prepuce  may  present  a  number  of  ulcerations,  and  at  the 
free  border  of  the  prepuce  small  radiating  ulcers  frequently  form.  In 
severe  chronic  cases  vegetations  appear  as  complications. 

The  course  of  the  disease  is  essentially  chronic,  and  as  a  result  of 
the  inflammation  and  of  the  ulcers  at  the  end  of  the  prepuce  well- 
marked  phimosis  may  be  caused.  In  very  severe  instances  the  ulcers 
lead  to  gangrene. 

In  some  cases  the  occurrence  of  balanitis  is  the  first  evidence  of  the 
existence  of  diabetes.  Whenever,  therefore,  these  conditions  pointing 
to  a  local  evidence  of  this  disease  are  observed  in  persons  who  had  pre- 
viously not  suffered  from  any  trouble  of  the  penis,  particularly  in  those 
of  middle  or  old  age,  the  suspicion  of  diabetes  should  be  entertained 
and  a  full  examination  made. 


COMPLICATIONS  OF  BALANITIS.  245 

Croupous  and  Diphtheritic  Balanitis. 

This  form  of  balanitis  is  usually  a  sequela  or  complication  of 
wounds  or  of  operations  upon  the  prepuce. 

The  clinical  appearances  consist  in  redness  and  swelling  of  the 
parts,  with  superficial  excoriation,  over  which  a  whitish  membranous 
exudation  as  thick  as  writing-paper  is  seated.  Usually  the  membrane 
is  readily  stripped  off,  and  healing  will  follow  the  observance  of  cleanli- 
ness and  the  application  of  a  mild  lotion. 

Diphtheritic  balanitis  is  sometimes  observed  during  or  following 
diphtheria,  scarlatina,  measles,  variola,  typhoid  fever,  and  other  infec- 
tious diseases.  The  local  affection  usually  originates  in  simple  balanitis 
resulting  from  want  of  cleanliness  and  care  in  the  removal  of  smegma 
and  of  decomposing  urine. 

The  membrane  in  this  form  of  balanitis  resembles  that  of  diph- 
theria of  the  mucous  membranes.  It  is  of  a  yellowish  or  dirty 
grayish-white  color,  sometimes  as  thick  as  blotting-paper,  and  is  with 
difficulty  removed  from  the  underlying  parts,  from  which  hemorrhage 
may  be  caused  by  the  operation.  The  glans  and  prepuce  are  reddened 
and  swollen,  and  may  even  become  phlegmonous.  In  bad  cases  the 
inguinal  ganglia  are  swollen.  Diphtheria  sometimes  attacks  the  cir- 
cumcision-wound in  young  infants. 

Balanitis  in  Syphilitic  Subjects. 

In  the  early  stage  of  syphilis,  coincidently  with  the  erythematous  or 
papular  rash,  balanitis  is  not  uncommon  in  persons  having  long  and 
tight  foreskins,  particularly  if  they  are  careless  in  the  matter  of  cleanli- 
ness. With  the  erythematous  syphilide  one  or  more  round  or  oval 
deep-red  excoriations  are  developed,  which,  as  a  result  of  uncleanli- 
ness,  may  invade  the  whole  glans  and  prepuce.  Mild  and  ephemeral 
in  its  course  as  this  specific  balanitis  is  in  cleanly  subjects,  it  may, 
owing  to  inattention,  be  followed  by  ulceration  and  diffuse  thickening 
of  the  parts. 

Complications. — While  balanitis  may  result  from  phimosis,  the 
latter  may  be  produced  by  balanitis.  Paraphimosis  may  also  result 
from  inflammation  of  the  prepuce  and  glans. 

Lymphangitis  of  a  mild  or  severe  type  is  not  at  all  infrequent  in 
severe  balanitis,  and  is  quite  common  when  that  affection  is  complicated 
with  chancroids  and  various  syphilitic  lesions,  also  with  gonorrhoea  and 
vegetations.  In  mild  cases  the  lymphatic  vessels  feel  like  cords  under 
the  foreskin.  In  severe  cases  the  whole  penis  becomes  of  a  deep  red 
color,  greatly  swollen,  oedematous,  and  the  seat  of  severe  pain — a  condi- 
tion incorrectly  called  "  penitis."     In  these  cases  phlegmonous  abscesses 


246 


AFFECTIONS  OF  THE  PEXIS. 


may  form  under  the  skin.  Following  lymphangitis  of  balanitic  origin, 
inflammation  of  the  inguinal  ganglia,  and  even  suppurating  buboes  may 
result. 

Xot  infrequently,  particularly  in  uncleanly  persons  in  diabetics,  also 
in  those  debilitated  by  disease  or  excesses,  gangrene  of  the  prepuce  occurs 
from  balanitis.     Owing  to  the  inflammation  of  the  parts  and  swelling  of 
.p,  the  glans,  a  black  spot  forms  about 

the  middle  of  the  prepuce,  and 
through  the  buttonhole-like  open- 
ing which  results  the  glans  pro- 
trudes.    (See  Fig.  74.) 

In  cases  of  recurrent  attacks 
of  acute  balanitis  thickening  of  the 
submucous  connective  tissue  is  not 
at  all  uncommon,  and  may  at  times 
present  points  of  resemblance  to 
syphilitic  or  infecting  balano-pos- 
thitis.  In  some  cases  of  acute 
balanitis  well-defined,  freely  mov- 
able, flat  plates  of  thickened  sub- 
mucous tissue  of  various  sizes  and 
extent,  which  can  be  readily 
grasped  between  the  thumb  and 
forefinger,  may  be  felt. 
Diagnosis. — In  mild  eases  the  diagnosis  of  balanitis  is  readily  made 
upon  retraction  of  the  prepuce.  However,  when  there  is  difficulty  of 
retraction,  the  case  may  be  mistaken  for  gonorrhoea.  If  the  orifice  of 
the  prepuce  is  large  enough  to  allow  inspection  of  the  meatus,  the  parts 
can  be  carefully  wiped,  and  then,  when  pressure  is  made  upon  the  under 
surface  of  the  urethra,  if  gonorrhoea  is  present  pus  will  exude  from  the 
meatus.  If  it  is  suspected  that  both  balanitis  and  gonorrhoea  are  present, 
the  meatus  may  be  carefully  plugged  with  a  little  ball  of  cotton,  and 
then  the  prepuce  may  be  compressed  from  behind  forward.  In  this 
way  a  correct  conclusion  may  be  reached. 

Herpes  progenitalis,  especially  when,  from  any  cause,  accompanied 
with  much  hyperemia,  may  at  first  be  mistaken  for  balanitis,  but  the 
history  of  the  case  may  be  of  aid,  and  upon  subsidence  of  the  inflam- 
mation the  sharply-limited  margins  of  the  vesicles  will  reveal  the  nature 
of  the  affection. 

The  most  difficult  task,  very  often,  in  the  diagnosis  of  balanitis  is  to 
determine  whether  or  not  chancroids  or  hard  chancres  lodged  under  the 
prepuce  are  at  the  bottom  of  the  trouble.  Chancroidal  ulcers  may  have 
been  seen  before  the  phimotic  balanitis  had  developed,  and  then  its 


CJaiiffrt 


)f  prepuce,  with  buttonhole-like 
opening  for  glans. 


TREATMENT  OF  BALANITIS.  247 

origin  is  clear.  But  in  many  cases,  from  carelessness  or  ignorance, 
patients  can  give  no  history  of  a  chancre  or  chancroid.  Subpreputial 
chancroids  are  attended  with  much  more  severe  and  rapid  inflammation 
than  simple  balanitis.  The  pus  becomes  very  copious,  less  thick  and 
creamy  than  in  simple  affection,  and  commonly  of  a  rusty  color.  Soon 
the  distal  end  of  the  penis  becomes  swollen,  in  shape  like  an  Indian 
club,  and  of  a  dusky-red  color  and  very  frequently  chancroids  are 
developed  by  auto-inoculation  around  the  preputial  orifice. 

Subpreputial  hard  chancres  producing  phimosis  may  be  mistaken  for 
simple  balanitis.  This  complication,  as  a  rule,  is  much  less  active  in  its 
nature  than  chancroidal  phimosis.  The  infection  increases  slowly,  usu- 
ally with  much  less  secretion  of  pus,  it  being  at  first  very  often  a  sero- 
pus.  The  oedema  increases  slowly,  is  more  aphlegmasic  or  less  red,  but 
rather  firmer.  The  diagnosis  is  usually  soon  cleared  up  by  the  develop- 
ment of  the  indurated  ganglia  in  the  groin,  and  perhaps  by  the  indura- 
tion of  the  lymphatics  and  veins  of  the  penis.  In  very  many  cases  it 
is  possible,  upon  careful  palpation,  to  determine  the  presence  of  a  well- 
defined  induration  under  the  prepuce.  It  must  be  remembered  that  sub- 
preputial vegetations  also  grow  slowly,  produce  phimotic  balanitis,  and 
feel  like  hard  chancres  under  the  prepuce.  The  secretion  accompany- 
ing them  is  profuse  and  of  a  disgusting  odor,  the  inflammatory  reaction 
is  rather  late  in  appearing,  and  the  lymphangitis  and  adenitis  are  less 
common  and  of  a  more  inflammatory  nature  than  in  the  phimotic  bala- 
nitis of  hard  chancre. 

It  is  sometimes  a  difficult  question  to  decide  whether  in  a  given  case 
phimotic  balanitis  is  caused  by  chancroids  or  vegetations,  and  sometimes 
it  can  be  done  only  after  incision  of  the  prepuce. 

Prognosis. — In  general,  the  prognosis  of  balanitis  is  good.  AVhen 
due  to  chancroids,  besides  the  destruction  of  the  prepuce  and  glans — 
and  perhaps  of  the  urethra— which  is  so  liable  to  occur  unless  proper 
treatment  is  instituted,  chancroidal  ulceration  in  the  lymphatics  and 
chancroidal  buboes  may  result.  Hemorrhage  also  is  very  common  and 
often  very  persistent,  and  phagedena  may.be  produced.  Balanitis  from 
hard  chancres  may  result  in  more  or  less  destruction  of  the  prepuce  and 
glans,  compression  and  stenosis  of  the  urethra,  and  phagedena. 

Balanitis  caused  by  early  syphilitic  lesions  is  easily  cured  if  early 
recognized  and  properly  cared  for. 

The  balanitis  of  elderly  persons,  with  its  epithelial  hyperplasia,  is  the 
source  of  great  annoyance  from  the  discomfort  produced  and  the 
hindrance  to  proper  cleanliness,  and  is  of  positive  danger  in  the 
tendency  which  it  induces  to  epitheliomatous  degeneration  of  the 
prepuce,  glans,  and  penis. 

Treatment. — Rigid  antisepsis  is  the  first  essential  in  the  treatment 


248  AFFECTIONS  OF  THE  PENIS. 

of  balanitis.  Mild  cases  may  be  readily  relieved  by  practising  scrupu- 
lous cleanliness  and  by  interposing  lint  or  absorbent  cotton  soaked  in 
boiled  or  distilled  water  between  the  prepuce  and  glans.  When  there  is 
much  excoriation  nitrate-of-silver  solution  (1  or  2  :  500)  is  often  very 
efficacious,  or  1  :  100  aluminum-acetate  solution  may  be  used.  Lead- 
water  and  laudanum  may  be  applied  if  there  is  much  inflammation. 

Solutions  of  sulphate  or  acetate  of  zinc  (1  :  100)  or  saturated  boric- 
acid  solution  are  sometimes  very  curative.  Aromatic  wine  and  lime- 
water  may  also  be  recommended. 

In  many  cases  dry  dressings  with  boric  acid,  calomel,  subnitrate  of 
bismuth,  nosophen,  aristol,  and  orthoform,  and  a  pledget  of  lint  or 
absorbent  cotton  are  very  beneficial. 

In  diphtheritic  balanitis  it  may  be  necessary  to  apply  strong  tincture 
of  iodine  sparingly. 

Balanitis  resulting  from  early  syphilitic  lesions  is  much  benefited  by 
the  use  of  black  or  yellow  washes,  which  are  also  beneficial  in  many 
cases  of  simple  balanitis. 

Copious  and  frequent  ablutions  of  the  parts  should  be  practised 
several  times  a  day,  and  when  there  is  any  tendency  to  phimosis  fre- 
quent injections  of  hot  water  slightly  alkalinized  by  borax,  or  a  mild 
solution  of  alum,  or  dilute  lead-water,  or  a  solution  of  bichloride  of 
mercury  (1  :  2000  to  5000)  or  of  carbolic  acid  (1  :  200),  should  fre- 
quently be  made. 

In  most  cases  of  chronic  balanitis,  particularly  in  elderly  men,  cir- 
cumcision is  urgently  indicated,  since  through  it  alone  can  permanent 
relief  be  obtained. 

HERPES    PROGENITALIS. 

Herpes  progenitalis,  by  some  incorrectly  called  "herpes  prepu- 
tialis,"  is  a  mildly  inflammatory  affection,  consisting  of  one  or  more 
vesicles  or  groups  of  vesicles.  It  occurs  in  both  sexes,  and  is  perhaps 
quite  as  frequent  in  the  female  as  it  is  in  the  male  sex.  In  men  it 
occurs  most  frequently  on  the  inner  surface  of  the  prepuce,  in  the  sulcus 
behind  the  corona,  on  each  side  of  the  frsenum,  on  the  lips  of  the 
meatus,  on  the  free  margin  of  the  prepuce,  upon  the  integument  of  the 
penis,  and  upon  the  pubic  region.  In  general,  the  vesicles  are  unilater- 
ally placed,  though  they  may  be  symmetrically  developed,  or  those 
seated  on  one  half  of  the  organ  may  encroach  on  the  other  half. 

In  women  herpes  progenitalis  occurs  on  the  inner  aspect  of  the  labia 
majora,  on  all  parts  of  the  labia  minora,  on  the  vestibule  and  prepuce  of 
the  clitoris,  at  the  orifice  of  the  urethra,  and  occasionally  on  the  outer 
surface  of  the  labia  majora  and  on  the  mons  Veneris. 

Development  and  Course. — The  evolution  of  the  affection  may 


HERPES  PROGENITALIS.  249 

occur  without  any  prodromal  symptoms  whatever :  sometimes  it  is  ante- 
dated by  various  neuralgic  phenomena,  but  in  most  cases  there  are 
slight  burning,  heat,  tickling,  and  itching  just  before  the  outbreak.  In 
nervous  and  chlorotic  women  an  intense  pruritus  often  begins  with,  and 
lasts  during,  the  attack.  General  morbid  states  seem  to  have  little 
influence  on  the  evolution  of  this  affection. 

The  eruption  may  consist  of  a  single  vesicle  or  it  may  consist  of  a 
group  closely  packed,  or,  again,  of  a  number  of  scattered  vesicles,  usu- 
ally following  the  course  of  a  nerve.  The  first  morbid  change  observed 
is  a  red  spot,  which  is  soon  the  seat  of  vesicles.  These  lesions  may  be 
of  the  size  of  a  pin's  head  or  of  the  diameter  of  a  line,  and  are  rounded, 
translucent  vesicles  containing  clear  serum.  When  seated  on  the  mucous 
membranes  they,  owing  to  the  succulence  of  the  parts  and  thinness  of 
the  epidermis,  soon  rupture ;  indeed,  it  is  very  rare  to  see  such  lesions 
intact.  When  seated  on  the  skin,  however,  they  may  remain  intact  for 
some  days,  and  unless  scratched  their  contents  become  turbid  and  they 
dry  into  brownish  scabs.  Rupture  of  the  vesicles  leaves  a  shallow 
exulceration  corresponding  in  size  to  that  of  the  vesicle.  Its  floor  is  at 
first  of  a  deep  rosy-red,  with  a  finely  uneven  surface,  and  its  edges 
sharply  cut  as  if  punched  out,  and  sometimes  undermined,  but  not,  as  a 
rule,  to  the  same  extent  as  in  chancroid.  When  there  is  a  group  of 
vesicles,  they  fuse  together  and  rupture,  forming  a  patch  which  has  been 
described  as  having  a  polycyclical  outline.  This  is  comparable  to  the 
outline  presented  by  two  pieces  of  three-leaf  clover  placed  base  to  base, 
which  then  has  a  festooned  margin  formed  by  segments  of  circles. 

Usually  the  vesicles  heal  in  a  few  days  ;  in  some  cases  they  are  very 
persistent,  and  in  others  they  become  ulcerated  and  indistinguishable 
from  true  chancroids.  In  this  state  their  secretion  is  sometimes  auto- 
inoculable,  and  in  some  cases  the  cause  of  buboes.  (See  section  on 
Chancroids.)  When  seated  on  an  inflamed  prepuce  and  irritated  by 
decomposed  smegma  or  gonorrheal  pus,  herpes  progenitalis  sometimes 
assumes  a  more  or  less  destructive  tendency.  Vesicles  may  become  cov- 
ered with  a  thin,  blackish,  very  adherent  crust,  and  thus  they  may 
remain  indolent  with  no  tendency  to  healing. 

When  fully  developed  there  is  usually  an  amelioration  or  subsidence 
of  the  itching,  heat,  or  burning,  but  somewhat  exceptionally  the  excori- 
ated surfaces  are  exquisitely  sensitive,  and  the  patient  shrinks  from  the 
slightest  touch  of  them.  Uncomplicated  cases  last  from  a  few  days  to 
two  weeks.  Untreated  cases,  particularly  in  uncleanly  subjects,  are 
sometimes  persistent  and  rebellious  to  treatment. 

In  exceptional  cases  there  are  swelling  and  pain  in  the  inguinal  gan- 
glia of  the  corresponding  side.  Sometimes,  when  the  vesicles  become 
much  inflamed  and  ulcerated,  suppurating  buboes  occur. 


250  AFFECTIONS   OF  THE  PENIS. 

Herpes  progenitalis  is  particularly  prone  to  relapse  at  longer  or 
shorter  intervals.  It  is  seen  mostly  in  young  adult  subjects,  and  it 
rarely  occurs  in  old  persons. 

Etiology. — Local  determining  conditions  are,  as  a  rule,  the  exciting 
causes  of  the  affection.  These  may  be  briefly  stated  as  any  or  all  con- 
gestions and  inflammations,  ephemeral  or  long  continued,  of  various 
grades,  affecting  one,  several,  or  all  portions  of  the  genito-urinary  tracts 
of  both  sexes.  Thus,  following  balanitis,  particularly  when  resulting 
from  phimosis,  gonorrhoea,  chancroids,  and  hard  chancres,  especially  in 
severe  instances,  herpes  progenitalis  frequently  appears.  In  patients 
suffering  from  strictures  and  those  having  lesions  in  the  posterior  urethra 
herpes  has  been  known  to  occur,  commonly  at  or  following  an  exacer- 
bation. Following  exploratory  operations  upon  the  urethra  and  bladder, 
particularly  when  protracted,  herpes  of  the  penis  has  been  found  to 
develop. 

As  causes  predisposing  to  herpes  progenitalis  in  the  male,  uncleanli- 
ness  and  decomposition  of  the  sebaceous  matter,  excessive  venery  and 
over-indulgence  in  alcoholics,  hot  weather,  obesity,  and  plethora  are  fre- 
quently noted.  The  neuropathic  condition  may  act  as  an  underlying 
predisposing  cause. 

In  women  as  in  men,  congestions  and  inflammations,  ephemeral  or 
long  continued,  are  always  the  underlying  causes  of  herpes  progenitalis. 
Prostitutes  are  those  who  suffer  in  greatest  number  from  this  affection, 
due,  undoubtedly,  to  the  very  frequent  irritation  of  their  genital  appa- 
ratus in  coitus.  Violence  to  the  female  genitals  in  rape  and  from  exces- 
sive size  of  the  penis,  and  in  masturbation,  particularly  when  large  and 
firm  substitutes  for  the  penis  are  employed,  often  produces  herpes  of  the 
parts.  Vulvitis,  vaginitis,  simple  or  severe,  are  frequently  the  fore- 
runners of  the  affection.  Congestion  of  the  pelvic  organs,  dymsenor- 
rhoea,  pelvic  cellulitis,  metritis,  inflammation  of  the  ovaries  and  tubes, 
and  endometritis  are  likewise  occasional  excitants  of  the  affection.  It 
is  also  a  frequent  forerunner  and  concomitant  affection  of  menstruation. 
During  this  epoch  it  frequently  attacks  young  girls,  young  women,  and 
even  those  of  middle  age.  The  attacks  may  come  on  every  month  or 
there  may  be  intervals  of  freedom  of  several  months.  It  is  perhaps 
rather  more  frequent  in  sexually-inclined  and  neurasthenic  women.  As 
in  men,  so  in  women,  herpes  progenitalis  is  seen  in  early  and  late  adult 
life,  and  found  to  relapse  in  the  same  exasperating  manner. 

It  is  probable  that  in  all  cases  of  herpes  progenitalis  disturbance 
occurs  in  the  nervous  arc  which  exists  between  the  genital  apparatus 
and  the  spinal  cord,  and  that  irritation  is  transmitted  from  the  external 
or  deep  portions  of  the  genital  apparatus  backward  to  the  spinal  nerve- 
centres,  and  from  these  conveyed  to  some  portion   or  portions  of  the 


HERPES  PROGENITALIS.  251 

penis,  vulva,  or  mons  Veneris.  Clinically,  many  cases  of  herpes  pro- 
genitalis  present  features  of  similarity  to  herpes  zoster,  even  to  the  point 
of  being  coexistent  with  it. 

Diagnosis. — Usually,  the  diagnosis  of  herpes  of  the  genitalia  is 
readily  made,  but  when  exulcerated  the  vesicles  may  closely  resemble 
chancroid  or  hard  chancre.  As  a  rule,  the  sensations  of  heat,  itching, 
and  burning,  the  superficial  character  of  the  lesion,  its  less  profuse 
secretion,  and  scarcely  undermined  edges  will  establish  the  diagnosis, 
which  may  be  strengthened  by  the  history  of  relapses.  Further,  the 
very  frequent  unilateral  position  and  peculiar  groupings  of  the  herpes 
vesicles  are  important  diagnostic  aids,  while  in  some  cases  the  arrange- 
ment of  these  lesions  in  the  course  of  a  nerve  points  undoubtedly  to 
their  nature. 

Both  in  its  solitary  and  multiform  conditions  herpes  may  resemble 
the  syphlitic  chancre  in  its  early  and  erosive  stage  (chancrous  erosion). 
There  are  probably  more  errors  made  by  mistaking  this  as  yet  undeveloped 
initial  lesion  for  herpes  than  there  are  about  any  other  form  of  the  hard 
chancre.  The  surface  of  the  chancrous  erosion  is  usually  of  a  deeper 
and  duller  red  color,  even  coppery,  and  its  floor  is  smooth  and  shining, 
without  any  small  granulations.  Its  areola  is  very  slight  and  of  a  dull- 
red  color,  and  there  is  a  general  absence  of  inflammation  about  the 
whole  lesion.  The  statement  has  been  made  with  much  positiveness 
that  pressure  between  the  thumb  and  forefinger  of  a  chancrous  erosion 
will  fail  to  cause  a  drop  of  serum  to  exude  from  its  surface,  while  if 
similarly  treated  a  herpetic  vesicle  gives  issue  to  repeated  drops.  This 
diagnostic  point,  in  my  judgment  should  be  interpreted  in  a  contrariwise 
direction.  Slight  pressure  of  the  chancrous  erosion,  will  cause  free 
exudation  of  serum,  while  similar  manipulation  of  herpetic  vesicles 
never  produces  more  than  a  scanty  secretion,  so  that  abundance  of 
secretion  is  at  least  presumptive  evidence  of  chancrous  erosions. 

It  is  a  good  rule  to  be  always  guarded  and  reserved  in  the  diagnosis 
of  these  minute  lesions,  particularly  in  cases  in  which  there  is  absence 
of  the  prodromal  and  accompanying  symptoms  of  herpes,  and  especially 
when  the  lesion  seems  particularly  insignificant.  This  point  cannot  be 
stated  in  a  too  impressive  manner.  It  is  these  insignificant  lesions 
which  usually  develop  into  hard  chancres.  In  like  manner,  a  clear 
history  of  antecedent  herpes  should  not  embolden  the  surgeon  to  speak 
too  confidently  of  the  simple  character  of  its  successor.  A  group  of 
chancrous  erosions  constitutes  what  is  called  the  multiple  herpetiform 
chancre,  which  is  liable  to  be  mistaken  for  a  cluster  of  herpetic  vesicles. 

Patches  of  chancrous  erosions  assume  a  round  or  oval  outline  or 
irregularly  round  or  oval  shape.  Herpes  progenitalis,  on  the  contrary, 
has  the  polycyclic  forms  with  its  festooned  and  segments-of-circles-like 


252  AFFECTIONS  OF  THE  PENIS. 

margins,  due  to  the  fusion  of  a  group  of  round  vesicles.  The  multiple 
herpetiform  chancre,  however,  may  present  for  a  few  days  a  typically 
distinct  polycyclic  outline. 

Treatment. — The  first  indication  is  to  remove  irritation  or  inflam- 
mation from  the  external  and  internal  parts  of  the  male  or  female 
genital  apparatus.  If  any  abnormality  of  the  prepuce  exists  as  a  pre- 
disposing cause,  circumcision  should  be  performed  as  early  as  possible 
after  the  healing  of  the  lesions,  since  benefit  is  produced  in  the  vast 
majority  of  cases.  Any  deep-seated  urethral  trouble  or  affection  of  any 
of  the  accessory  parts  of  the  genital  tract  should  receive  appropriate 
treatment.  All  sources  of  irritation  of  the  penis  should  be  avoided, 
and  frequent  ablutions  in  hot  water  made.  Any  coexisting  dyscrasia — 
gouty,  rheumatic,  neurotic,  or  plethoric — should  receive  proper  atten- 
tion.    Sexual,  alcoholic,  and  dietary  excesses  should    be   interdicted. 

In  women,  as  far  as  possible,  irritations,  congestions,  and  inflamma- 
tions should  be  avoided  or  removed  by  appropriate  treatment,  and  the 
frequent  use  of  douches  of  hot  water  should  be  insisted  upon.  The 
health  of  the  patient  should  be  considered,  and  any  deviation  from  the 
normal  attended  to. 

In  the  matter  of  local  treatment  it  is  important  to  observe  the  most 
scrupulous  cleanliness  of  the  parts,  which  should  be  carefully  washed 
twice  daily  in  soap  and  water  and  irrigated  with  bichloride  solution 
(1  :  2000).  In  very  irritable  cases  immersion  of  the  penis  in  very  hot 
water  is  indicated.  In  these  cases  also  the  lead -and-opi urn  wash  is 
very  beneficial. 

Black  and  yellow  washes  and  aromatic  wine  are  very  useful  applica- 
tions, and  in  many  cases  the  red  wash  (1  per  cent,  sulphate  of  zinc  dis- 
solved in  water  and  perfumed  with  compound  spirits  of  lavender)  will 
produce  prompt  healing.  As  dry  applications,  aristol,  orthoform,  xero- 
form,  antinosine,  and  europhen  may  be  of  service  in  many  cases. 

In  the  somewhat  rare  cases  in  which  there  is  tendency  to  ulceration 
it  may  be  necessary  to  resort  to  the  application  of  iodoform.  When 
the  case  is  treated  on  rigid  antiseptic  lines,  the  tendency  to  ulceration 
and  inguinal  adenitis  will  be  seldom  seen. 

VEGETATIONS. 

Vegetations  are  papillary  new-growths  formed  by  hypertrophy  of  the 
papilla?,  increase  in  the  epidermis  and  capillaries,  and  hyperplasia  of 
connective  tissue. 

Vegetations  are  not,  in  the  majority  of  cases,  of  venereal  origin, 
though  their  most  frequent  sites  of  development  are  on  or  in  the  neigh- 
borhood of  the  genitals  of  both  sexes,  particularly  in  persons  who  have 
had  gonorrhoea,  leucorrhcea,  chancroids,  and  syphilis,  and  in  pregnant 


SOFT   VEGETATIONS.  253 

women.  It  is  incumbent  upon  the  physician  to  be  very  careful  in  the 
employment  of  the  word  "venereal"  as  applied  to  warts,  for  great  in- 
justice may  be  done  to  patients,  male  and  female,  in  whom  these  lesions 
may  be  present,  but  who  may  not  have  been  guilty  of  sexual  trans- 
gression. Their  growth  is  induced  and  favored  on  mucous  surfaces 
and  at  the  junction  of  the  skin  and  mucous  membrane,  and  on  thin, 
delicate  skin  by  uncleanliness,  by  the  decomposition  of  sweat  and  of 
sebaceous  matter,  and  by  the  presence  of  gonorrhceal  and  other  kinds 
of  pus.  For  clearness  of  description,  vegetations  may  be  divided  into 
two  well-marked  classes  :  first,  the  soft,  succulent  warts  of  the  mucous 
membranes  and  mucocutaneous  junctions  ;  second,  the  harder  and  firmer 
warts  which  appear  on  the  skin,  particularly  near  the  genitals,  since 
here  the  two  factors  essential  to  their  growth — namely,  heat  and  mois- 
ture— exist. 

Soft  Vegetations. 

Vegetations,  especially  of  the  soft  kind,  are  mostly  seen  in  subjects 
of  from  twelve  years  to  adult  life,  and  in  the  male  and  female  in  about 
equal  proportions.  As  age  advances  they  are  less  frequently  observed, 
and  in  middle-aged  and  old  persons  they  are  harder,  firmer,  and  sessile, 
less  vascular,  and  fewer  in  numbers,  most  commonly  resembling  the 
chronic  seed-warts  of  the  hands. 

Vegetations  begin  as  minute  reddened  erosions  of  the  mucous  mem- 
brane, which  very  soon  come  to  look  like  pinhead-sized,  rosy-red,  finely- 
granular  papules.  In  this  state  they  may  be  mistaken  for  incipient  hard 
chancres.  From  this  insignificant-looking  lesion  growths  even  of  vast 
size  spring.  When  the  parts  are  moist  and  little  attention  is  paid  to 
cleanliness,  they  grow  rapidly  and  exuberantly,  but  where  the  parts  are 
dried  they  grow  slowly  and  show  less  tendency  to  peripheral  develop- 
ment. The  close  coaptation  of  parts,  with  their  greater  inaccessibility 
to  care  and  their  increased  secretions,  also  favors  rapid  growth.  The 
pinhead-sized  warts  already  described  grow  in  height  and  in  breadth  and 
form  vegetations  of  various  shapes.  They  may  be  rounded  and  sessile 
or  pedunculated  or  Indian-club-  and  mushroom-shaped,  in  which  condi- 
tions they  vary  in  size  from  that  of  a  pea  to  that  of  a  raspberry.  Or, 
instead  of  growing  in  breadth,  when  from  the  formation  of  the  parts 
they  are  subjected  to  lateral  pressure,  they  grow  to  a  length  of  an  inch 
and  more,  and  separated  they  look  like  so  many  thin  red  spears  with 
smooth  red  sides  jutting  out  and  radiating  in  various  directions. 

Moderately  developed  vegetations  in  the  coronal  sulcus  and  on  the 
inner  layer  of  the  prepuce  are  well  shown  in  Fig.  75. 

The  exuberant  development  of  warts  of  the  sessile  and  pedunculated 
or  club-shaped  forms  may  result  in  new  growths  of  enormous  size  which 
are  called  fungating  masses  and  cauliflower  excrescences.     (See  Fig.  76.) 


254 


AFFECTIONS  OF  THE  PENIS. 


The  color  of  vegetations  varies  in  different  subjects  and  at  different 
times.  They  may  be  of  the  deep  red  of  the  cock's  comb,  or  of  a  pur- 
plish red,  and  when  rather  small  they  may  be  but  slightly  more  pink 

Fig.  75. 


Soft  young  vegetations  in  the  coronal  sulcus  and  near  fraenum. 

than  the  mucous  membrane  upon  which  they  are  seated ;  frequently 
they  are  of  a  gray  or  dirty-gray  color.  Their  surface  is  covered  with 
minute,  mammillated  warty  elevations  resembling  those  of  the  straw- 
berry or  raspberry.     (See  Fig.  76.) 

Fig.  76. 


Exuberant  warts  involving  the  inner  layer  of  the  prepuce,  the  sulcus,  and  the  greater  portion  of 
the  glans  (cauliflower  appearance;. 

Various  annoying  and  injurious  mechanical  conditions  are  sometimes 
caused  by  vegetations  in  both  male  and  female.  Men  having  the  vari- 
ous malformations  of  the  prepuce,  such  as  smallness  of  the  orifice, 
straitness  and  tightness  and  redundancy,  and  those  in  whom  the  fnenum 


-*r 


CORNEOUS  VEGETATIONS.  255 

is  short,  upon  the  development  of  warts  on  these  parts  are  very  liable 
to  phimosis.  This  complicated  condition  is  often  accompanied  by  much 
inflammatory  action,  with  a  copious  flow  of  pus.  Warts  thus  concealed 
under  the  prepuce,  the  conditions  being  so  favorable,  grow  rapidly, 
sometimes  pushing  forward  and  out  of  the  preputial  orifice,  and  again 
they  press  upward,  causing  gangrene  and  perforation  of  the  prepuce. 

When  seated  about  the  frcenum  they  first  cause  difficulties  in  retract- 
ing the  foreskin,  and  later  on  phimosis  or  paraphimosis. 

In  women  vegetations  at  the  meatus  and  in  the  vestibule  very  often 
give  rise  to  irritation,  often  severe  in  character,  spasmodic  pains,  burn- 
ing, and  a  discharge,  and  sometimes  a  frequent  desire  to  pass  water,  and 
they  may  act  as  an  impediment  to  urination.  In  the  vulva  and  around 
the  introitus  vaginas,  besides  these  inflammatory  accompaniments,  when 
small  they  interfere  with  the  introduction  of  specula  and  with  coitus, 
and  when  excessively  large,  even  to  the  size  of  an  egg  or  an  orange, 
they  impede  urination  and  effectually  block  up  the  vaginal  orifice. 
Cure  of  such  cases  often  involves  partial  stenosis  of  the  orifice. 

In  women  warts  about  the  vulva  sometimes  lead  to  great  hypertrophy 
and  disfigurement  of  the  parts. 

Corneous  Vegetations. 

The  hard  or  corneous  warts  of  the  skin  may  exist  alone  or  follow  the 
successive  crops  of  soft  ones  which  begin  on  mucous  surfaces.  They 
consist  of  small  red,  sometimes  dirty-brown,  sessile,  rounded  or  pointed 
tumors,  quite  firm  in  structure,  of  an  area  of  a  line  or  more,  and  of  a 
height  of  two  or  more  lines.  The  features  are  usually  very  striking 
and  in  marked  contrast  to  condylomata  of  syphilis.  In  structure  they 
are  similar  to  the  soft  ones,  except  that,  owing  to  the  nature  of  the  skin, 
their  epidermal  covering  is  thicker,  their  papilla?  shorter,  and  the  con- 
nective tissue  more  condensed.  They  occur  on  the  penis,  on  the  scrotum, 
in  the  crural  folds,  and  about  the  anus  in  the  male,  and  on  the  labia 
majora,  inner  surface  of  the  thighs,  on  the  perineum,  and  about  the  anus 
in  women.  Like  those  of  the  soft  variety,  they  increase  in  great 
numbers,  though  more  slowly.  On  coapted  surfaces  their  epithelial 
covering  may  be  rubbed  off,  and  they  then  give  issue  to  a  sticky,  fetid 
secretion,  which,  mixed  with  sebum  and  sweat,  is  sometimes  copious. 
Their  further  course  is  influenced  by  the  conditions  which  surround 
them.  If  the  parts  are  the  seat  of  heat  and  moisture,  especially  if  the 
patient  is  uncleanly,  they  grow  and  multiply  luxuriantly ;  but  if  they 
occur  on  exposed  surfaces,  and  particularly  if  they  are  carefully  cleansed 
or  dusted  with  absorbent  powders,  they  may  remain  quiescent  indefi- 
nitely. In  like  manner,  the  soft  warts,  when  seated  on  parts  which  can 
be  kept  dry  and  are  either  exposed  to  the  air  or  to  the  action  of  absorb- 


256  AFFECTIONS  OF  THE  PENIS. 

ent  powders,  become  hard  and  corneous  and  permanently  lose  their 
softness  and  succulence. 

Diagnosis. — So  well  marked  are  the  features  of  full-developed 
vegetations  that  their  nature  is  readily  recognized.  When,  however, 
they  have  undergone  condensation  and  have  become  flattened,  they  may 
be  mistaken  for  condylomata  lata,  especially  when  the  latter  have  be- 
come hypertrophic.  The  latter  usually  have  a  clear  syphilitic  history, 
and  are  perhaps  accompanied  by  other  specific  lesions,  active  or  de- 
clining. Condylomata  lata  begin  as  small  flat,  papular,  firmly -consist- 
ent formations,  usually  of  slow  growth  at  first,  not  very  many  in 
number,  and  may  thus  remain  for  a  long  time ;  whereas  the  vegetations 
or  warts  grow  rapidly  and  present  the  clearly-cut  features  already 
given.  The  hard  form  of  wart  found  in  older  subjects  is  very  often 
a  sign  of  evil  omen.  Portions  should  be  removed  and  their  nature 
determined  by  the  aid  of  the  microscope. 

Prognosis. — Though  of  simple  nature,  vegetations,  from  their  great 
exuberance  of  growth,  should  never  be  slightingly  regarded.  The  fre- 
quent causation  of  acute  purulent  inflammation  in  both  male  and  female, 
their  tendency  to  induce  phimosis,  with  gangrene  and  perforation  of  the 
prepuce,  and  paraphimosis,  their  interference  with  the  functions  of  the 
female  genito-urinary  tract,  and  their  liability  when  large  to  become 
gangrenous,  should  be  borne  in  mind  and  explained  to  patients.  Further, 
their  inevitable  growth  and  reproduction  should  not  be  forgotten.  Then, 
again,  particularly  in  old  subjects,  they  are,  as  we  have  seen,  prone  to 
undergo  malignant  degeneration — usually  in  women  earlier  than  men. 
It  may  be  stated,  without  fear  of  contradiction,  that  a  large  proportion 
of  the  cases  of  epithelioma  of  the  uterus  and  vagina  and  of  the  penis 
have  begun  in  a  seemingly  insignificant  wart.  It  is  the  duty  of  the  sur- 
geon to  impress  upon  the  patient  the  fact  that  as  middle  age  approaches 
and  increases,  warts  on  any  portion  of  the  body  are  menaces  to  his  or 
her  safety.  This  is  particularly  true  as  to  the  genital  organs  of  both 
male  and  female.  An  aged  male  patient,  having  from  any  cause  diffi- 
culty in  retracting  the  prepuce  with  warts  around  or  beneath  it,  should 
be  informed  that  they  are  especially  prone  at  his  time  of  life  to  undergo 
malignant  degeneration. 

Treatment. — The  indications  for  the  treatment  of  vegetations  are 
their  complete  removal  and  the  prevention  of  their  return.  In  every 
instance  the  immediate  and  accessory  parts  should  be  thoroughly  washed 
and  irrigated  with  bichloride  solution  (1  :  2000),  then  the  surfaces 
and  interstices  of  the  warts  should  be  thoroughly  coated  with  an  8 
per  cent,  solution  of  muriate  of  cocaine. 

It  may  be  stated  as  an  axiom  that  thorough  curetting  for  the  removal 
of  vegetations  is  much  more  rapid  and  effectual  than  caustics  and  the 


HORNY  GROWTHS.  257 

galvano-cautery.  When  the  vegetations  are  small,  they  are  readily  re- 
moved by  the  dermal  curette  or  sharp  spoon,  the  scraping  being  carried 
well  to  the  level  of  the  tissues,  which,  however,  must  not  be  wounded.  A 
solution  of  persulphate  or  perchloride  of  iron  should  be  carefully  touched 
to  the  bleeding  points,  and  the  parts  when  dry  quite  firmly  covered  either 
with  iodoform  or  absorbent  gauze — never  with  watery  solutions.  Such  is 
the  tendency  to  recurrence  of  these  growths  that  the  cure  cannot  be 
considered  complete  until  the  surfaces  are  smooth.  In  cases  of  recur- 
rence before  the  little  growths  have  reached  much  salience,  chloro-acetic 
acid,  the  caustic  solution  of  lead,  or  the  iron  solutions  just  mentioned 
should  be  carefully  and  thoroughly  applied. 

Large  and  exuberant  vegetations  should  be  treated  in  the  same  way. 

There  is  a  popular  fallacy  that  warts  in  pregnant  women  should  not 
be  removed  for  fear  of  producing  abortion.  This  view  was  the  out- 
come of  the  old  and  now  happily  nearly  obsolete  treatment  by  vigorous 
and  intemperate  cauterization,  which  produced  great  vulvar  and  vaginal 
inflammation,  and  sometimes  rigidity,  even  stenosis,  of  the  genital  tract. 
No  such  results  are  produced  when  the  growths  are  removed  by  curet- 
ting in  the  manner  already  described.  The  removal  of  vegetations  by 
ligation  is  to  be  condemned. 

After  removal  the  surgeon  should  explain  to  the  patient  the  condi- 
tions under  which  warts  grow  and  luxuriate,  with  a  view  to  prevent 
their  recurrence. 

In  persons  beyond  forty  years  of  age  persistent  recurrence  of  an 
originally  simple  wart  should  always  awaken  suspicion  of  malignancy, 
and  prompt  radical  extirpation  should  be  practised. 

HORNY  GROWTHS. 

True  horny  growths  of  the  penis  are  rather  rarely  seen,  and  there 
are  in  literature  less  than  twenty  cases  reported. 

These  growths  are  of  two  kinds  :  first,  horny  plates  of  varying  thick- 
ness, which  may  extend  in  depth  and  constitute  a  distinct  nodule,  or 
consist  of  a  band  or  ring  encircling  the  glans  penis  ;  and  second,  pro- 
jecting horns.     In  some  cases  both  forms  of  new-growth  are  present. 

Horns  of  the  penis  take  their  origin  in  the  coronal  sulcus  and  on  the 
inner  aspect  of  the  prepuce,  particularly  near  the  frsenum.  They  can 
better  be  pictured  than  described. 

In  Figs.  77  and  78  are  portrayed  the  features  of  the  remarkably  strik- 
ing case  of  Pick.  The  large  horn  sprang  from  the  prepuce  and  glans, 
its  base  being  imbedded  like  a  nail  in  its  matrix  on  the  right  side  down 
toward  the  frsenum.  From  its  base  the  horn  jutted  downward,  and 
upward  to  the  left  and  in  front  of  the  meatus.     From  the  base  of  the 

17 


258 


AFFECTIONS  OF  THE  PENIS. 


glans  several  small  horns  sprang  and  showed  a  tendency  to  come  up- 
ward in  front  of  the  glans.  When  the  penis  was  placed  in  line  with 
the  abdomen  the  large  horn  presented  an  appearance  not  unlike  the 
crest  of  a  dragoon's  helmet.     The  horn  was  two  and  a  half  inches  lono-. 


Fig.  77. 


Fig.  78. 


Horn  of  the  penis.    (After  Pick.) 


There  may  be  but  one  horn  or  there  may  be  several.  They  are  of 
varying  lengths,  from  half  an  inch  to  three  and  a  half  inches  long.  In 
all  the  reported  cases  they  were  curved  when  they  had  attained  a  length 
of  an  inch.  They  vary  in  breadth  at  the  base  according  to  their  size, 
and  gradually  taper  off  toward  their  distal  portion,  which  is  usually 
truncated.  As  a  rule,  they  give  rise  to  no  pain,  though  some  patients 
have  complained  of  itching  and  even  burning  sensation.  They  act  as 
mechanical  hindrances  to  coitus,  and  may  more  or  less  impede  or  obstruct 
urination.  In  some  cases  epithelioma  has  been  known  to  coexist  with 
and  follow  ablation  of  these  growths.  They  are  mostly  seen  in  men 
of  from  fifty  to  seventy  years,  but  they  have  been  observed  as  early  as 
the  nineteenth  year  of  life. 


ELEPHANTIASIS  OF  THE  GENITALS.  259 

Microscopically,  horny  growths  of  the  penis  are  seen  to  consist  of 
fibrillated  layers  of  densely-packed  epidermic  cells. 

The  treatment  of  these  growths  is  by  thorough  ablation,  taking  away 
portions  of  or  the  whole  of  the  glans  if  necessary.  They  sometimes 
return  after  removal. 

ELEPHANTIASIS   OF   THE   GENITALS. 

Elephantiasis  of  the  male  and  female  genitals  occurs  in  rare  and 
sporadic  cases  in  America,  England,  and  on  the  continent  of  Europe, 
but  is  quite  common  and  endemic  in  tropical  and  subtropical  countries. 

Elephantiasis  consists  of  a  hypertrophy  of  the  fibrous  tissue  of  the 
cutis  and  subcutaneous  connective  tissue,  and  is  attended  with  recur- 
rent inflammation  of  the  vessels  and  lymphatics. 

The  disease  generally  begins  as  a  hard  kernel,  usually  under  the  skin, 
at  the  bottom  of  the  left  side  of  the  scrotum.  This  kernel  enlarges  in 
size,  and  thus  the  surrounding  parts  are  invaded.  As  the  affection 
increases  the  surface  of  the  scrotum  becomes  thickened  and  indurated, 
is  readily  pitted  on  pressure,  and  appears  furrowed,  channelled,  wrinkled, 
and  nodular. 

As  the  scrotum  becomes  large  and  heavy  it  drags  down  the  adjacent 
skin  of  the  abdomen,  which  is  incorporated  into  the  scrotal  mass.  In 
most  cases  the  organ  is  slowly  absorbed  into  the  scrotal  mass  till  it 
becomes  completely  hidden  in  the  tumor.  Its  cutaneous  covering  is 
connected  merely  to  the  glans,  and  forms  a  blind  canal  whose  aperture 
is  situated  in  front  in  the  median  line,  which  forms  a  kind  of  outward 
extension  of  the  urethra.  Sometimes  a  gutter  is  formed  in  the  scrotal 
tissue,  beginning  at  the  urethral  opening  and  running  down  to  the  bot- 
tom of  the  tumor.  The  skin  of  this  gutter  may  be  converted  into 
mucous  membrane.  In  some  cases  the  tumors  have  been  known  to 
become  very  large,  varying  in  size  and  volume  until  they  reached 
to  the  feet.  In  this  condition  the  patient  often  carries  his  genitals 
-before  him  on  a  wheelbarrow.  Such  tumors  on  removal  may  weigh 
from  fifty  to  two  hundred  pounds  and  over. 

Elephantiasis  of  the  penis  is  much  rarer  than  the  scrotal  affection 
and  usually  begins  in  the  prepuce.     (See  Fig.  79.) 

When  elephantiasis  of  the  genitals  is  very  much  developed,  there  is 
frequently  observed  to  ooze  from  the  scrotum  a  yellowish  serous  fluid, 
which  escapes  from  the  elongated  and  dilated  lymphatics  that  have 
become  ruptured. 

In  sporadic  cases  of  elephantiasis  of  the  penis  there  is  usually 
a  history  of  some  irritative  process  which  antedated  the  onset  of  the 
hypertrophy. 

Treatment. — In  some  cases  amputation  of  the  penis  may  be  neces- 


260 


AFFECTIONS   OF  THE  PENIS. 


sary,  particularly  in  those  in   which  there  is  a  urethral  fistula  in  the 
body  of  the  penis.     In  other  cases  removal  of  the  mass  of  hypertro- 

Fig.  79. 


Elephantiasis  of  the  penis. 

phied  tissue  may  be  practised,  the  incisions  being  made  according  to  the 
topography  of  the  parts  with  a  view  of  getting  such  flaps  as  will  after 
healing  give  a  tolerably  symmetrical  organ.  It  is  the  unanimous 
opinion  of  operators  that  even  if  flaps  are  taken  from  the  hypertrophied 
tissue,  they  do  not  form  the  focus  of  new  development. 

When  the  scrotal  mass  becomes  very  large  and  unwieldy  it  should 
be  removed,  excepting  such  an  amount  of  tissue  as  may  be  required  to 
cover  the  testes. 

BENIGN  NEW-GROWTHS. 

The  penis  is  sometimes  the  seat  of  a  variety  of  new-growths,  which 
produce  little  if  any  deformity  and  rarely  require  surgical  intervention. 

Milia  are  not  infrequently  found  in  the  cutaneous  investment  of  the 
organ.     They  require  no  treatment. 

Sebaceous  Tumors. — These  new-growths  are  not  very  uncom- 
monly found  scattered  over  the  scrotum,  and  in  some  instances  a  few 
may  be  seated  in  the  integument  of  the  penis.  When  by  reason  of  their 
size  they  are  objectionable,  they  may  be  (after  proper  sterilization  of  the 
parts)  removed  by  incision  and  enucleation. 

Erectile  Tumors. — In  exceptional  cases  nsevi  are  found  on  the  penis, 


FRACTURE.  261 

most  commonly  on  the  glans.  The  new-growth  consists  usually  of  the 
flat  form  of  nsevus  and  consists  of  a  patch,  bluish  or  purplish  in  color — 
the  so  called  port-wine  mark.  In  some  rare  cases  a  tuberous  growth  of 
more  or  less  extent  and  elevation  is  found,  and  in  very  exceptional 
instances  the  glans  is  the  seat  of  well-marked  vascular  hypertrophy. 
As  a  rule,  no  treatment  is  required  for  these  cases.  Exceptionally  elec- 
trolysis may  be  required  to  cause  the  excessive  growth  of  vessels  to 
diminish  and  wither. 

A  varicose  condition  of  the  large  veins  of  the  integument  of  the 
penis  is  sometimes  observed,  but  it  is  rarely  of  such  marked  develop- 
ment as  to  require  a  surgical  operation. 

Fatty  Tumor. — In  very  rare  instances  a  fatty  tumor  has  been  found 
in  the  integument  of  the  penis.  Such  cases  should  be  treated  on  general 
surgical  principles. 

FRACTURE. 

This  accident  is  quite  uncommon,  and  generally  occurs  in  coitus  and 
exceptionally  during  sleep.  It  may  be  complete,  the  cavernous  bodies 
and  spongy  body  being  totally  broken  or  incomplete,  in  which  condition 
one  cavernous  body  or  the  spongy  body  alone  may  be  fractured. 

The  first  symptom  is  a  sudden  stabbing  pain,  and  then  swelling  of 
the  organ  rapidly  supervenes.  When  the  corpora  cavernosa  are  in- 
volved, the  swelling  is  on  the  dorsum  and  sides  of  the  penis,  and, 
according  to  the  amount  of  extravasation  of  blood,  is  large  or  small. 
Pain,  distention,  and  unwieldiness  are  prominent  symptoms.  In  some 
cases  the  fractured  ends  have  been  found,  and  on  motion  crepitation  has 
been  produced. 

Fracture  of  the  corpus  spongiosum  may  occur  as  the  result  of  a  blow 
on  the  penis  when  curved  in  chordee ;  it  more  commonly,  however,  is 
the  result  of  violent  efforts  in  coitus,  sometimes  in  the  bridal  bed,  but 
generally  as  an  incident  in  a  drunken  debauch.  In  the  cases  of  fracture 
of  the  spongy  body,  the  parts  rapidly  swell,  owing  to  the  escape  of 
blood,  and  unless  prevented  by  the  prompt  use  of  the  catheter,  extrava- 
sation of  urine  occurs,  in  which  event  the  penis  becomes  greatly  swollen 
from  the  base  to  the  glans.  In  cases  of  urethral  rupture  retention  of 
urine  is  a  frequent  and  troublesome  symptom. 

In  some  unrelieved  cases  fever  and  even  pyaemia  may  be  observed, 
and  abscesses,  destructive  ulceration,  and  gangrene  may  occur  and  lead 
to  the  development  of  urethral  fistula?. 

Fracture  of  the  penis  is  observed  in  old  and  young  subjects.  In 
advanced  life  the  sheath  of  the  corpora  cavernosa  is  sometimes  more 
condensed  and  brittle  than  normal,  and  it  is  then  more  liable  to 
fracture. 


262  AFFECTIONS   OF  THE  PENIS. 

Prognosis. — The  prognosis  of  fracture  of  the  penis  varies  according 
to  the  extent  and  seat  of  the  injury.  When  the  cavernous  bodies,  one 
or  both,  are  fractured  the  parts  may  heal,  and  erections  may  thereafter 
be  perfect,  or  erection  may  only  occur  in  the  proximal  part  of  the  penis, 
while  the  distal  part  remains  flaccid. 

Treatment. — In  mild  cases  rest  in  the  recumbent  position  and  the 
application  of  cooling  lotions  may  be  all  that  is  necessary,  except  the  in- 
troduction of  a  soft  catheter  to  empty  the  bladder.  When  the  extravasa- 
tion of  blood  is  very  great,  it  may  be  necessary  to  make  a  free  incision, 
and  then  treat  the  wound  antiseptically.  Ulceration  and  gangrene  of 
the  parts  should  be  treated  on  the  regular  surgical  lines.  All  collec- 
tions of  pus  should  be  incised  and  the  parts  antiseptically  dressed. 

The  outcome  in  cases  of  rupture  of  the  corpus  spongiosum  is  usu- 
ally a  traumatic  stricture  of  rapid  growth  and  much  density.  (See 
page  170,  et  seq.) 

Rupture  of  the  corpus  spongiosium  usually  requires  the  regular 
passage  of  a  catheter,  and  perhaps  its  retention  for  a  longer  or  shorter 
period.  Free  incisions  and  external  urethrotomy  should  be  performed 
when  extravasation  of  urine  has  occurred,  and  when  blood-extravasa- 
tion is  extensive,  particularly  when  injurious  pressure  is  produced.  As 
the  swelling  in  these  cases  is  usually  so  great  that  the  urethra  cannot  be 
reached  and  promptly  stitched,  it  is  necessary  to  await  events,  and  when 
the  stricture  is  forming  to  endeavor  to  restore  the  urethral  calibre  by 
the  introduction  of  sounds,  and,  in  the  failure  of  this  effort,  to  resort 
to  urethrotomy. 

CURVATURE. 

This  condition  is  sometimes  found  in  patients  whose  organ  has  not 
been  injured.  In  some  cases  the  curvature  is  slight  and  upward ;  in 
others  moderately  downward ;  and  in  still  others  there  is  a  decided 
twist  of  the  organ,  usually  to  the  left. 

Various  anomalies  of  the  penis  may  be  accompanied  by  curvature 
of  the  organ.  The  most  common  cause  of  slight  curvature  is  shortness 
of  the  frsenum,  which,  as  a  rule,  is  readily  relieved  by  operation. 

In  some  rare  cases  the  septum  of  the  corpora  cavernosa  forms  a 
distinct  string  or  cord  just  above  the  corpus  spongiosum,  and  it  draws 
the  penis  toward  the  scrotum.  This  condition  also  may  be  relieved 
by  operation. 

Hypospadias,  with  adhesion  to  the  scrotum,  is  a  rare  condition,  and 
is  usually  complicated  with  curvature  of  the  penis,  due  in  some  cases  to 
the  cord-like  condition  of  the  septum  of  the  corpora  cavernosa.  This 
condition  may  be  much  improved  or  relieved  by  operation. 

Congenital  adhesion  of  the  penis  without  hypospadias  is  sometimes 


OSSIFICATION.  263 

found.  In  this  state  the  penis  is  either  wholly  enveloped  by  the  scrotal 
tissue,  or  it  is  attached  by  its  inferior  surface  to  the  bag  by  means  of  a 
webbed  band  of  integument,  called  webbed  penis.  The  glans  is  usu- 
ally free,  and  from  the  meatus  the  urine  dribbles  downward.  The 
penis  being  thus  bound  down,  when  it  becomes  erect  it  is  curved  down- 
ward and  intromission  is  impossible. 

Curvature  of  the  penis  from  shortness  of  the  corpus  spongiosum  is 
quite  rare.  A  dense  and  inelastic  condition  of  the  spongy  body,  either 
congenital  or  the  result  of  gonorrhoeal  inflammation,  in  some  rare  cases 
leads  to  downward  curvature,  which  cannot  be  thoroughly  relieved  by 
operation. 

Injury  to  the  corpora  cavernosa  from  abscess,  gummatous  infiltra- 
tion, partial  or  complete  fracture,  and  thrombosis  may  result  in  curva- 
ture of  the  penis.  In  fibroid  sclerosis  and  ossification  of  these  struct- 
ures this  deformity  is  a  permanent  symptom. 

Temporary  curvature  of  the  penis  may  occur  during  phimosis  and 
paraphimosis. 

Within  the  past  twenty  years,  in  which  extremely  large  incisions 
into  and  overdilatation  of  the  urethra  have  been  so  extensively  practised, 
it  has  not  been  uncommon  to  see  many  distressing  cases  of  curvature 
of  the  penis,  in  some  of  which  intromission  was  impossible,  while  in 
others  coitus  could  be  indulged  in  only  with  great  difficulty  and  discom- 
fort. In  many  of  these  cases  the  distress  of  the  patient  was  increased 
by  the  resulting  sexual  debility,  which  in  some  cases  amounted  to  im- 
potence. As  a  rule,  curvature  of  the  penis  the  result  of  intemperate 
instrumentation  is  permanent  and  wholly  refractory  to  medical  and 
surgical  treatment. 

Treatment. — In  some  cases  of  short  frsenum  and  in  which  the  penis 
is  bound  down  to  the  scrotum  relief  may  be  obtained  by  operation. 
When  the  curvature  occurs  as  the  result  of  traumatism  or  of  intem- 
perate operations  on  the  urethra  no  relief  can  be  offered  by  surgical 
procedures. 

OSSIFICATION. 

This  affection  is  very  rare,  and  is  denominated  calcification  by  some 
authors.  It  occurs  in  middle-aged  and  old  men  ;  hence,  as  a  rule,  it 
does  not  cause  much  mental  disturbance,  though  it  may  interfere  with 
and  even  entirely  prevent  coitus.  The  parts  involved  are  the  sheaths 
of  the  corpora  cavernosa  and  the  septum  pectiniforme.  The  bony  growth 
may  be  in  plates,  as  it  is  usually  found  in  the  superficies  of  the  corpora 
cavernosa,  or  in  rod-shape  when  the  septum  pectiniforme  is  attacked. 

Ossification  of  the  penis,  which  is  partial,  takes  place  very  insidiously 
and  without  pain,  and  the  patient  first  becomes  aware  of  its  existence 


264  AFFECTIONS  OF  THE  PENIS. 

by  the  impediment  it  offers  to  coitus  or  the  curvature  which  it  causes  to 
the  organ.  In  a  reported  case  in  which  there  was  so  much  distortion 
of  the  penis  that  urination  was  accomplished  with  the  greatest  difficulty, 
the  whole  length  of  the  septum  was  ossified,  and  coitus  was  rendered 
impossible.  Curvature  of  the  penis  either  upward  or  downward  may 
accompany  the  condition. 

Treatment. — When  the  bony  plates  are  superficial,  if  the  patient  is 
importunate,  they  may  be  removed,  but  in  all  cases  bad  distortion  of 
the  penis  is  likely  to  follow  cutting  operations. 

DISLOCATION. 

In  rather  rare  instances  as  the  result  of  traumatism,  chiefly  by 
machinery  and  revolving  wheels,  the  penis  is  torn  from  its  cutaneous 
sheath  and  is  forced  into  the  scrotum,  perineum,  or  under  the  integu- 
ment of  the  abdomen.  In  these  cases  the  mucous  membrane  at  the 
coronal  sulcus  is  torn,  and  the  cutaneous  sheath  is  found  not  to  contain 
the  penis  but  to  be  filled  with  clotted  blood. 

Retention  of  urine  is  a  prominent  symptom  of  this  condition,  and 
usually  leads  to  a  careful  examination  of  the  genitals,  which  reveals  the 
nature  of  the  dislocation. 

Treatment. — After  the  parts  have  been  rendered  surgically  clean, 
an  incision  is  made  at  the  base  of  the  penis,  the  organ  is  liberated  and 
replaced,  and  the  parts  are  properly  sutured.  If  in  these  cases  the 
urethra  has  been  ruptured,  it  is  necessary  to  perform  external  ure- 
throtomy promptly  (see  section  on  Traumatic  Stricture,  p.  175). 

Contusions  and  traumatisms  of  the  cutaneous  investment  of  the 
penis  should  be  treated  on  general  surgical  principles,  either  when  they 
are  or  are  not  coexistent  with  dislocation. 

ABNORMALITIES  IN   THE   SIZE   OF   THE   PENIS. 

Cases  of  rudimentary  penis  have  been  recorded  as  well  as  those  of 
the  infantile  type ;  they  are,  however,  of  rare  occurrence.  A  case  of 
bifid  penis,  in  which  the  glans  and  a  part  of  the  body  of  the  organ  were 
split  and  the  urethral  opening  was  seated  back  and  behind  the  bifurca- 
tion, is  on  record  as  a  classical  illustration  of  this  rare  anomaly. 

Rudimentary  penis  is  of  rare  occurrence,  and  is  usually  coexistent 
with  cryptorchism  or  some  other  sexual  anomaly.  A  case  has  been 
reported  by  Dummreicher  in  which  a  boy  of  twelve  had  a  penis  which 
was  only  three-fourths  of  an  inch  long  and  as  thick  as  a  goose-quill. 
The  corpora  cavernosa  were  absent. 

We  sometimes  meet  cases  of  men  of  various  ages  in  which  the  penis 
is  no  larger  than  that  of  a  child,  and  in  which,  as  a  rule,  the  testes  are 
very  small.     In  some  of  these  cases  a  decided  increase  in  the  size  of  the 


ABNORMALITIES  IN  THE  SIZE  OF  THE  PENIS.  265 

organ  takes  place  when  coitus  is  regularly  indulged  in.  Instances  of 
decidedly  undersized  penis  with  long,  tight  prepuce  have  been  observed, 
which  became  much  larger  after  the  parts  were  circumcised. 

Absence  of  the  penis  is  a  very  rare  anomaly. 

Cases  of  enlargement  of  the  penis,  so  that  it  constitutes  a  monstrosity, 
are  relatively  rare.  I  know  of  an  individual  in  whom  the  organ  when 
erect  was  said  to  be  fourteen  inches  long  and  proportionally  thick.  This 
man  had  two  wives  who  died  of  uterine  disease,  while  a  third  applied 
for  a  divorce  very  soon  after  marriage. 

In  the  average  run  of  cases  of  penis  of  excessive  size  the  man  may 
have  connection  with  some  women  without  injury  to  them,  provided 
care  and  tact  are  observed.  I  had  under  my  care  many  years  ago  a 
man  who  had  been  shot  in  the  groin  and  in  whom  injury  to  the  lymph- 
atics had  been  produced.  Following  this  wound  the  penis  began  to 
swell  and  grow  in  length  until  it  measured  eleven  inches  in  the  supple 
state. 

Elephantiasis  of  the  penis  leads  to  large  deformities.  In  phimosis, 
particularly  when  intrapreputial  chancres  and  chancroids  are  present, 
the  penis  often  becomes  of  large  size.  When  the  hard  oedema  of  syphilis 
attacks  this  organ,  it  becomes  greatly  enlarged  in  all  directions. 

Double  Penis. 

This  anomaly  is  very  rare,  and  is  usually  found  in  cases  of  that 
monstrosity  called  foetal  inclusion. 

Preputial  Calculi. 

A  peculiar  form  of  distortion  of  the  penis,  which,  when  well  marked, 
produces  organic  impotence,  is  caused  by  the  presence  of  calculi  in  the 
preputial  sac.  There  may  be  one,  two,  or  three  calculi  present,  and  the 
distortion  of  the  organ  varies  according  to  their  number  and  size.  As 
a  rule,  intromission  of  the  penis  becomes  impossible  and  coitus  so  pain- 
ful that  it  is  usually  not  indulged  in  by  these  sufferers. 

Preputial  calculi  may  be  seated  side  by  side  and  may  then  be  sym- 
metrically faceted  to  each  other,  or  one  stone  may  be  seated  on  the  top 
of  the  other  in  a  concavity  in  which  the  convex  base  of  its  upper  fellow 
is  smoothly  placed.  It  is  said  that  preputial  calculi  are  not  very  uncom- 
mon in  China,  particularly  in  the  persons  of  the  natives. 

Treatment.— When  it  is  practicable  these  calculi  should  be  removed 
by  taxis.  When  they  are  firmly  held  by  a  phimotic  prepuce,  it  will  be 
necessary  to  make  lateral  incisions  into  the  appendage,  and  when  the 
foreign  bodies  are  removed,  full  circumcision  may  be  performed  (see 
page  230). 


266  AFFECTIONS  OF  THE  PENIS. 

FIBROID   SCLEROSIS   OF   THE   CORPORA    CAVERNOSA. 

This  affection  has  heretofore  been  described  under  the  title  of  chronic 
circumscribed  inflammation  of  the  corpora  cavernosa,  an  obvious  mis- 
nomer, since  no  one  has  ever  observed  any  inflammatory  condition  con- 
nected with  it. 

This  affection  begins  slowly,  painlessly,  and  insidiously,  and  as  a 
rule,  is  first  recognized  by  the  patient  as  a  little  bean-like  lump  or  plate 
of  tissue  in  the  sheath  of  the  corpora  cavernosa,  which  may  be  slightly 
painful  on  pressure  or  during  erection. 

In  exceptional  cases  the  patient  complains  of  pain  in  the  penis,  par- 
ticularly on  erection,  when  on  careful  palpation  no  change  in  the  corpora 
cavernosa  can  be  made  out,  even  after  several  examinations.  In  these 
cases  the  only  evidences  of  lesion  are  the  tendency  of  the  penis  to  curve 
upward  and  the  presence  of  pain  when  an  attempt  is  made  to  straighten 
the  curved  organ.  In  these  cases  the  fibroid  proliferation  is  well  under 
way,  but  it  has  not  become  sufficiently  compact  to  cause  such  a  change 
in  the  tissues  as  to  be  perceptible  to  the  fingers. 

As  a  rule,  the  sclerosis  is  tolerably  well  advanced  when  the  surgeon 
is  consulted,  and  he  finds  a  hard,  firm  plate  of  tissue  a  line  or  two  in 
thickness,  perhaps  the  size  of  one's  thumb-nail  or  larger,  seated  in  the 
superficial  portion  of  the  corpora  cavernosa,  about  equally  on  each  side 
of  the  median  line,  like  a  saddle.  Its  margins  are  usually  sharply 
defined  and  regular,  or  they  may  exceptionally  be  uneven,  slightly 
nodulated,  and  perhaps  thickened.  The  deeper  parts  are,  as  a  rule,  free 
from  the  disease,  but  exceptionally  we  find  that  the  morbid  process  has 
extended  downward  into  the  trabecule.  The  induration  of  the  plate 
is  variable ;  in  the  early  stages  it  is  not  usually  very  dense,  but  in  older 
cases  it  may  be  of  cartilaginous  hardness.  Usually  these  plates  present 
a  kind  of  elasticity  which  differs  from  that  of  the  bony  and  cartilaginous 
plates  sometimes  found  here.  As  the  plates  grow  old  they  become  very 
dense  and  inelastic. 

The  lesion  may  occupy  one  corpus  cavernosum  or  both  of  them,  but 
it  generally  seems  to  begin  on  the  dorsum  of  the  penis  near  the  median 
line,  and  extends  in  the  shape  of  a  saddle.  Sometimes  a  small  ovoid 
plate  is  found  on  one  side  of  the  penis.  The  plates  and  saddle-like 
patches  may  grow  to  be  two  or  three  inches  long.  As  a  rule,  the  scle- 
rosis attacks  the  corpora  cavernosa,  but  quite  exceptionally  it  involves 
the  corpus  spongiosum. 

As  a  rule,  we  find  but  one  saddle-like  plate,  but  in  some  instances 
there  are  two,  one  just  behind  the  glans  penis,  and  the  other  further  up 
the  organ,  near  its  root.  Another  anomalous  form  of  this  affection 
consists  in  the  usual  saddle-like  lesion  with  one  or  two  small  plaques 
seated  on  one  or  both  sides  of  the  corpora  cavernosa. 


FIBROID  SCLEROSIS  OF  THE  CORPORA    CAVERNOSA.  267 

These  plates  may  grow  in  all  the  directions  of  their  margin,  but 
usually  to  a  greater  extent  in  an  anteroposterior  direction.  They  not 
infrequently  remain  stationary  for  a  long  period,  but  usually  extend 
quite  slowly  and  insidiously. 

In  the  majority  of  cases  the  lesion  runs  its  course  in  the  flat  super- 
ficial manner  just  described ;  but  in  some  instances  the  sclerosing  pro- 
cess extends  deeper  into  the  trabeculated  tissue  of  the  corpora  covernosa 
and  produces  nodular  masses  of  varying  size. 

This  affection  interferes  more  or  less  with  erection,  according  to  the 
size  of  the  plaque.  If  this  is  small,  it  may  cause  but  slight  distortion 
of  the  penis ;  but  as  it  grows  larger,  it  so  interferes  with  the  proper 
erection  of  the  organ  that  it  is  bent  exceptionally  almost  to  a  right- 
angle,  but  usually  upward  and  toward  the  affected  side,  or  it  may  be 
somewhat  twisted.  In  most  cases  the  erectile  tissue  underlying  the 
lesion  in  the  whole  length  of  the  organ  becomes  hard  and  firm  during 
erection.  When  the  trabeculated  tissues  have  become  deeply  infiltrated, 
the  penis  beyond  them  is  not  at  all  congested,  while  the  erection  in  the 
proximal  part  is  complete.  In  this  event  the  organ  may  resemble  a 
flail,  the  firm  part  near  the  body  being  the  handle,  and  the  distal  part 
or  swingel  hanging  flaccid,  perhaps  nearly  at  a  right-angle. 

In  general,  patients  having  plates  in  the  dorsum  of  the  penis  com- 
plain that  when  erect  the  end  of  the  organ  stands  so  near  the  abdom- 
inal wall  that  intromission  is  rendered  impossible,  and  any  attempt 
at  straightening  it  out  is  attended  with  severe  pain. 

This  affection  is  peculiar  to  those  of  middle  and  advanced  age.  As 
a  rule,  these  patients  present  themselves  when  about  fifty  years  old,  and 
from  that  time  on  to  sixty  or  seventy  years.  Close  interrogation  of 
intelligent  patients  thus  affected  usually  brings  out  no  facts  as  to  its 
origin.  In  some  exceptional  cases  there  is  a  vague  recollection  of  trau- 
matism, but  as  a  rule  nothing  can  be  learned  from  the  patient  as  to  the 
cause  of  his  trouble. 

Etiology. — We  have  no  precise  knowledge  as  to  the  cause  of  this 
affection.  By  some  it  is  thought  to  be  the  result  of  a  gouty  condition, 
and  by  others  that  it  is  caused  by  diabetes,  but  neither  of  these  assump- 
tions is  based  on  scientific  evidence.  My  own  opinion  is  that  trauma- 
tisms are  the  primary  exciting  causes  in  all  cases. 

Pathology. — Observations  have  shown  that  these  nodules  resemble 
microscopically  keloid,  their  being  a  fibrous  network  of  tissue  like  that 
of  scars,  with  few  vessels  and  islets  of  embryonic  cells,  showing  a  ten- 
dency to  fibrous  transformation.  In  short,  the  process  is  a  chronic 
fibrous  sclerosis.  The  statement  that  this  affection  is  caused  by  throm- 
bosis of  the  venous  spaces  is  not  supported  by  any  scientific  evidence. 

Two  cases  have  been  reported  in  which  cancerous  degeneration  was 


268  AFFECTIONS  OF  THE  PENIS. 

found  in  sclerotic  plates  ;  but  their  details  are  so  unsatisfactory  in  many 
particulars  that  no  accurate  conclusions  can  be  drawn  from  their  studies. 
This  much  may  be  said — namely,  that  no  evidence  of  malignancy  is 
found  in  the  development  and  course  of  the  majority  of  cases.  It  must 
be  remembered  that  operations  based  on  a  diagnosis  of  cancer  in  these 
cases  are  wholly  unwarranted  in  the  present  state  of  our  knowledge. 

Prognosis. — This  is  very  unsatisfactory  since  there  are  no  authenti- 
cated cases  on  record  in  which  improvement  or  involution  of  the 
sclerosis  has  been  observed. 

Treatment. — Little  can  be  done  for  this  affection.  Most  patients 
desire  at  least  to  make  an  effort  to  remove  their  disability.  In  this 
spirit  mild  blisters,  mercurial  inunctions,  applications  of  iodine  and 
ichthyol,  and  the  use  of  the  constant  current  may  be  tried,  and  for  a' 
time  iodide  of  potassium  may  be  given  internally.  Such,  however,  is 
the  uncertainty  of  ultimate  favorable  results  that  one  is  not  warranted 
in  causing  these  patients  inconvenience  or  suffering. 

PRIAPISM. 

"While  in  the  normal  state  erections  last  only  a  short  time,  in  certain 
morbid  conditions  they  are,  on  the  contrary,  of  prolonged  duration,  and 
constitute  a  condition  to  which  the  term  priapism  is  applied. 

In  cases  of  true  priapism  the  erections  are  painful,  persistent,  and 
irreducible,  and  are  unaccompanied  by  sexual  desire.  Much  latitude 
has  been  accorded  to  the  term  priapism,  since  under  it  have  been  classed 
several  orders  of  cases  which  really  are  only  instances  of  slightly  pro- 
longed and  moderately  painful  erection,  due  to  an  obvious  cause.  "We 
may  divide  this  affection  into  the  following  classes : 

1.  Priapism  observed  in  infants  and  children,  induced  by  reflex 
action  in  cases  of  long,  tight,  adherent  prepuce,  of  stone  in  the  bladder 
or  prostatic  urethra,  and  of  worms  in  the  rectum. 

2.  Priaprism  in  adult  subjects,  symptomatic  of  stone  in  the  bladder, 
stone  in  the  prostatic  urethra,  stricture,  cystitis,  and  observed  during 
retention.  In  these  cases  the  uneasy  or  painful  sensation  is  felt  in  the 
glans  penis,  while  the  body  of  the  organ  usually  is  only  moderately  con- 
gested and  sometimes  curved  downward  or  laterally.  This  condition 
disappears  upon  removal  of  the  cause. 

3.  Priapism  symptomatic  of  gonorrhoea,  with  perhaps  involvement 
of  the  corpus  spongiosum  and  downward  curvature.  This  condition  is 
painful  and  transitory,  and  may  occur  several  times  during  the  night. 
In  cases  of  downward  curvature  of  the  penis,  due  to  inflammatory 
engorgement  of  the  corpus  spongiosum  and  spasm  of  the  musculature 
of  the  urethra,  the  term  chordee  is  applied. 


PRIAPISM  DUE  TO  SEXUAL  AND  ALCOHOLIC  EXCESS.        269 

4.  Priapism  due  to  ingestion  of  cantharides,  which  is  a  form  that  is 
seldom  or  never  seen  now,  since  this  drug  is  so  rarely  used  in  medicine. 

5.  Essential  priapism. 

It  is  unnecessary  here  to  consider  the  first  four  forms  of  so-called 
priapism,  as  they  are  merely  examples  of  intercurrent  symptoms,  usually 
of  short  duration,  of  well-known  morbid  or  structural  conditions,  and, 
as  a  rule,  are  relieved  by  operation  or  medical  treatment. 

We  may  divide  essential  priapism  into  four  varieties  : 

1.  Priapism  caused  by  injury  to  the  spinal  cord  (either  high  up  or 
low  down),  and  by  blows  or  violence  inflicted  upon  the  perineum  ; 

2.  Priapism  which  is  a  symptom  of  cerebral  or  descending  spinal- 
cord  disease ; 

3.  Priaprism  which  occurs  after  alcoholic  and  sexual  excesses ;  and 

4.  Priapism  which  comes  on  a  person  in  ill  health,  in  whom  it  is 
difficult  to  obtain  data  as  to  local  injury  and  causation,  and  in  which 
cases  there  is  now  a  tendency  to  look  upon  leukaemia  as  the  etiological 
factor. 

Priapism  after  Spinal  Injury. 

In  this  form  of  priapism  the  traumatism  has  been  found  as  high  up 
as  the  cervical  and  as  low  down  as  the  lumbar  and  sacral  region. 
When  the  injury  is  in  the  cervical  region  it  is  probable  that  irritation 
of  the  nerves  which  pass  down  the  cord  to  the  sexual  centre  is  the 
cause  of  the  trouble,  and  that  the  priapism  is  due  to  excitation  com- 
municated to  the  erigentes.  When  the  damage  is  inflicted  low  down 
it  is  probable  that  the  sexual  centre  is  so  irritated  that  it  is  thrown 
into  a  state  of  chronic  excitation,  which  shows  itself  in  the  engorge- 
ment of  the  penis.  The  course  of  these  cases  depends  upon  the 
extent  and  severity  of  the  injury ;  in  some  the  integrity  of  the  parts 
is  restored  and  the  priapism  ceases.  In  others,  death  occurs  sooner  or 
later. 

Priapism  in  Cerebral  and  Descending  Spinal  Disease. 

There  are  a  few  recorded  cases  of  this  kind,  and  our  knowledge  of 
the  subject  is  very  unsatisfactory.  Cases  of  priapism  coexistent  with 
cerebral  and  spinal  congestion,  spinal  syphilis,  and  locomotor  ataxia 
have  been  reported. 

Priapism  due  to  Sexual  and  Alcoholic  Excess. 

The  greater  number  of  cases  of  priapism  may  be  denominated 
alcoholico-erotic  cases,  since  the  trouble  usually  has  its  origin  in  a 
drunken  sexual  debauch.  As  a  rule,  the  greater  number  of  those  who 
surfer  from  this  form  are  young  and  vigorous  men,  although  medical 


270  AFFECTIONS  OF  THE  PENIS. 

annals  show  that  men  in  middle  and  advanced  life  furnish  a  moderate 
contingent. 

The  mode  of  onset  in  cases  of  erotic  priapism  differs.  In  some 
cases  there  is  for  a  time  increased  frequency  of  erections,  which  are 
premonitory  and  last  a  few  or  many  minutes ;  in  others,  after  sexual 
intercourse,  the  rigidity  of  the  penis  remains  and  becomes  persistent ; 
while  in  still  others  the  patient,  on  awakening  from  his  debauch,  finds 
that  he  is  suffering  from  priapism.  In  most  cases  when  the  opportunity 
exists,  these  patients  endeavor  to  relieve  themselves  by  coitus,  and  they 
always  fail.  In  exceptional  cases  orgasm  and  emission,  without 
pleasurable  sensations,  occur ;  but,  as  a  rule,  there  is  no  sexual  desire, 
and  ejaculation  is  not  produced.  In  fact,  it  is  stated  that  in  several 
cases  the  suffering  of  the  patient  was  materially  increased  by  coitus. 

During  attacks  of  priapism  the  state  of  the  penis  has  been  found  to 
present  several  variations  in  different  cases.  In  its  most  severe  form 
the  organ  becomes  much  enlarged,  tense,  and  comparable  to  cartilage  in 
rigidity,  and  the  seat  of  severe  pain.  The  glans  may  be  double  in  size, 
much  distended,  and  glistening,  as  if  it  would  burst.  The  corpora 
cavernosa  are  very  dense  and  unyielding  to  pressure  in  their  whole 
length,  including  their  crura.  The  corpus  spongiosum  is  likewise  hard 
and  swollen,  and  its  bulbous  expansion  is  in  a  similar  condition. 

In  some  cases  the  perineal  muscles  can  be  felt  as  dense  fibrous  bands, 
and  the  dorsal  vein  of  the  penis  seems  much  distended  and  feels  like  a 
whipcord. 

In  many  of  these  cases  attentive  examination  reveals  very  painful 
spots  or  perhaps  nodules  in  the  corpora  cavernosa,  particularly  toward 
their  root  or  in  the  crura.  Then,  again,  digital  pressure  on  the  bulb 
and  over  the  perineal  muscles  may  cause  an  agony  of  pain.  Spasm  of 
the  cremaster  muscles  may  be  present,  and  the  testes  then  are  drawn 
forcibly  up  to  the  internal  ring.  This  symptom  may  be  wanting.  In 
some  cases  there  is  pain  in  the  lower  part  of  the  back  and  along  the 
course  of  the  spermatic  cords.  Redness  and  swelling  of  the  prepuce 
may  be  observed  as  complications.  As  a  rule,  the  integument  of  the 
penis  retains  its  normal  color. 

In  this  pronounced  condition  the  sufferings  of  the  patient  are  very 
severe,  and  many  authors  apply  the  term  atrocious  to  the  pain  which  is 
seated  in  the  virile  organ.  The  patients  fear  the  least  touch  of  their 
linen  or  of  the  bedclothes,  and  jarring  of  the  bed  or  heavy  steps  in  the 
room  cause  them  agonizing  suffering.  They  draw  up  their  legs  upon 
the  abdomen  in  order  to  protect  the  penis  from  the  slightest  touch. 
This  organ  may  lie  rigid  against  the  abdomen,  or  it  may  be  more  or 
less  erect  and  at  a  right  angle  with  the  body  in  the  horizontal  position. 
Very  soon  these  patients  become  much  worried  and  apprehensive,  and 


PRIAPISM  DUE  TO  SEXUAL  AND  ALCOHOLIC  EXCESS.       271 

their  faces  give  evidence  of  anxiety  and  suffering.  In  these  cases  uri- 
nation may  be  accomplished  either  with  little  difficulty,  or  the  act  may 
be  painful,  slow,  and  halting,  with  a  small  sputtering  stream,  or  the 
patient  may  have  to  assume  the  knee-elbow  position  in  order  to  expel 
the  urine  from  the  bladder. 

The  atrociously  painful  symptoms  are  usually  spasmodic  in  char- 
acter, but  the  attacks  may  be  very  frequent  and  much  prolonged,  in 
which  event  insomnia,  nervous  exhaustion,  and  general  prostration 
supervene.  In  this  way  the  man  suffers  from  day  to  day,  sometimes 
experiencing  very  little  amelioration  of  his  condition  for  days  or  weeks. 
In  many  cases,  however,  there  are  intervals  of  comparative  freedom 
from  suffering,  in  which  the  hyperesthesia  and  turgidity  of  the  organ 
are  somewhat  diminished  and  the  patient  may  have  some  much-needed 
sleep. 

The  duration  of  severe  priapism  may  be  from  two  or  three  to  six 
consecutive  weeks,  and  even  longer. 

There  is  usually  no  fever,  particularly  in  young,  robust  men,  but  in 
older  subjects  having  leukaemia  or  visceral  lesions  pyrexia  may  be 
observed. 

In  contrast  to  the  foregoing  very  severe  forms  of  priapism  we  observe 
cases  in  which  the  organ  is  less  tense  and  distended,  and  in  which  the 
mental  and  physical  suffering  is  not  very  severe.  In  somewhat  excep- 
tional cases  the  patients  suffer  but  little  pain,  and  the  discomfort  exper- 
ienced in  the  turgidity  of  the  organ  is  the  chief  symptom. 

It  is  not  the  rule  to  find  priapism  involving  the  corpora  cavernosa 
and  corpus  spongiosum  at  the  same  time.  Some  cases  have  been 
observed  in  which  the  glans  and  the  whole  corpus  spongiosum  have  been 
lax  and  extensible ;  others  in  which  the  turgescence  of  one  cavernous 
body  was  very  severe  while  its  mate  was  more  supple,  and  others,  again, 
in  which  the  rigidity  was  unequally  felt  in  the  length  of  the  corpora 
cavernosa. 

While,  as  a  rule,  the  invasion  of  this  trouble  is  prompt,  even  sudden, 
and  severe,  its  involution  is  always  slow  and  often  halting,  and  attended 
with  disheartening  relapses.  The  first  sign  of  improvement  is  the  dim- 
inished rigidity  of  the  organ,  which  soon  becomes  less  painful,  and  thus 
the  case  progresses  until  the  normal  state  is  reached.  In  that  happy 
event  the  patient  cannot  be  said  to  be  entirely  out  of  danger,  for  the 
reason  that  recurrences  may  follow  at  short  or  long  intervals,  particu- 
larly if  the  patient  is  guilty  of  sexual  or  alcoholic  indulgence  or  excess, 
is  subjected  to  wet  or  cold,  or  is  constrained  to  undergo  severe  bodily 
exertion. 

From  the  records  of  the  various  published  cases,  the  inference  seems 
to  be  warranted  that  in  about  one-half  of  the  cases  the  patient  is  left 


272  AFFECTIONS  OF  THE  PENIS. 

impotent.  It  would  be  unwise,  however,  to  state  this  as  a  rule  or 
law,  since  the  publication  of  cases  usually  follows  quite  promptly  upon 
their  occurrence.  It  may  be  that  permanent  impotence  is  induced, 
or  the  condition  may  be  of  temporary  duration.  In  young  and  vigor- 
ous men  it  is  to  be  presumed  that  their  virility  will  later  on  be 
re-established. 

Etiology. — While  the  etiology  of  this  form  of  priapism  cannot  be 
clearly  stated,  certain  suggestions  may  be  made  as  to  its  causation.  In 
some  cases  there  is  strong  evidence  that  damage  has  been  done  to  the 
corpora  cavernosa,  particularly  near  their  roots.  This  is  shown  in  the 
tender  spots  and  the  hard  nodules  left  after  involution  of  the  affection. 
Then,  again,  in  some  cases  there  is  a  probability  of  blood-extravasation 
into  the  areolae  of  the  cavernous  tissue.  Whether  or  not  in  these  alco- 
holico-erotic  cases  there  has  been  irritation  of  the  sexual  centre  and  of 
the  nervi  erigentes,  or  whether  there  has  been  injury  to  the  sympathetic 
nerve,  we  cannot  say. 

In  all  probability  traumatism,  though  unrecognized,  is  the  essential 
cause  in  all  cases. 

Priapism  of  Leukemic  Origin.    (?) 

There  is  a  class  of  cases  of  priapism  in  young  men,  but  particularly 
in  men  of  middle  and  advanced  life,  in  which,  during  and  after  a  more 
or  less  prolonged  period  of  ill-health,  this  symptom  appears. 

The  clinical  history  of  this  form  is  similar  to  that  already  portrayed, 
but  in  general  there  is  an  absence  of  any  data  as  to  excesses  of  any 
kind.  In  this  form  we  find  cases  with  the  pronounced  agonizing  group 
of  symptoms  and  cases  in  which  lesser  degrees  of  priapism  and  suffer- 
ing have  been  experienced.  In  these  cases  there  is  a  history  either 
of  neurasthenia,  mental  worry  and  depression,  or  of  malarial  fever 
and  leukaemia,  sciatica,  hemicrania,  and  numbness  and  cramps  in  the 
muscles. 

Owing  to  the  fact  that  leukaemic  blood-changes  and  enlargement  of 
the  liver  and  spleen  have  been  observed  in  most  of  these  cases,  some 
authors  unhesitatingly  accept  leuksemia  as  the  cause  of  the  priapism, 
while  others  speak  less  confidently.  While  I  am  not  prepared  to  deny 
that  priapism  may  be  etiologically  related  to  leukaemia,  I  am  free  to 
confess  that  on  the  evidence  thus  far  submitted  this  relation  is  in  no 
manner  made  clear,  and  the  suspicion  forces  itself  upon  one's  mind  that 
perhaps  the  occurrence  was  a  coincidence.  The  trouble  with  the  re- 
ported cases  is  that  the  antecedent  history  of  the  patient  has  not  been 
thoroughly  gone  into. 

The  facts  have  not  been  established  that  there  has  been  no  alcoholic 
or  sexual  indulgence,  or  in  some  cases  that  injury  to  the  penis  has  not 


PRIAPISM  OF  LEUKEMIC  ORIGIN.  273 

occurred.  Having  the  leuksemic  explanation  in  mind,  this  thought 
seems  to  have  guided  the  various  authors  in  their  estimate  and  treat- 
ment of  the  case,  and  they  have  failed  to  pursue  channels  of  investiga- 
tion which  might  reveal  some  local  injury  to  the  sexual  tract. 

Prognosis. — Few  definite  statements  can  be  made  as  to  the  prognosis 
of  priapism  of  any  form.  In  those  cases  in  which  injury  to  the  corpora 
cavernosa  or  thrombosis  can  be  made  out,  incisions  may  greatly  expedite 
the  cure.  The  existence  of  spinal  disease  necessitates  a  guarded  prog- 
nosis. In  very  much  run-down  neurasthenic  subjects,  in  sexual  per- 
verts, and  in  those  suffering  from  leukaemia  the  chances  are  that  the 
priapism  will  be  very  persistent,  and  when  it  disappears  that  it  will  be 
very  liable  to  undergo  relapse. 

Treatment. — In  surveying  the  results  of  treatment  of  the  cases  of 
priapism  already  published,  one  is  forced  to  the  opinion  that  nothing 
like  a  routine  method  can  be  laid  down.  Remedies  which  have  pro- 
duced more  or  less  good  in  one  man's  hands  have  failed  in  those  of 
another.  This  much,  however,  can  be  stated  with  emphasis  :  Chloro- 
form narcosis  has  failed  in  every  case  in  which  it  has  been  used ;  ice 
usually  does  more  harm  than  good  ■  electricity  has  no  value,  and  may 
even  be  harmful;  and  leeches,  to  the  number  of  sixteen  and  forty,  have 
failed  to  produce  any  amelioration  in  the  condition  of  the  penis,  and 
have  been  injurious  in  their  depletory  effects. 

My  own  preference  is  to  resort  early  to  moderate  and  tentative 
incisions  into  the  most  turgid  part,  or  into  parts  the  seat  of  continuous 
pain,  or  into  nodular  masses,  in  all  probability  the  result  of  traumatism. 
Under  antiseptic  procedures  there  is  no  longer  any  fear  of  fever,  pro- 
fuse suppuration,  or  pyaemia,  which  were  observed  in  cases  treated 
before  the  new  era  in  surgery.  With  a  clean,  incised  wound  we  need 
not  have  the  scarring,  nodulation,  or  loss  of  the  tissues  of  the  cavernous 
bodies,  which  almost  always  occurred  in  former  years. 

It  is  always  good  practice  in  priapism  to  use  iodide  of  potassium 
alone  or  in  combination  with  mercury  when  a  history  of  antecedent  or 
present  syphilis  is  elicited. 

Bromide  of  potassium,  chloral,  belladonna,  and  morphine  may  be  of 
benefit,  especially  during  paroxysms ;  lupuline,  camphor,  and  cannabis 
indica  have  been  used  with  indifferent  results,  and  the  same  may  be 
said  of  ergot  and  strychnine. 

Of  local  applications,  the  following  may  be  found  to  be  beneficial : 
hot  baths,  hot  and  cold  spinal  douches,  sponging  with  very  hot  water, 
spinal  cauterization,  anodyne  poultices,  and  perhaps  ice-bags,  but  the 
last  must  be  guardedly  used. 

Any  ephemeral  or  systemic  disorder  should  be  appropriately  treated. 

18 


274  AFFECTIONS  OF  THE  PENIS. 

GANGRENE. 

In  rather  rare  cases  the  penis  is  attacked  by  gangrene  which  condi- 
tion may  also  synchronously  or  subsequently  invade  the  scrotum  and 
perineum. 

Gangrene  of  the  penis  is  usually  observed  in  its  moist  form,  and, 
exceptionally,  dry  gangrene  attacks  the  organ. 

The  part  most  commonly  affected  is  the  prepuce,  and  in  many  cases 
the  lesion  is  limited  to  this  appendage ;  but  in  some  cases  the  whole 
tegumentary  envelope  of  the  penis  is  destroyed,  and  in  very  severe  cases 
the  glans  and  erectile  tissues  become  involved.  In  the  worst  form  of 
cases  the  whole  penis  together  with  the  scrotum  and  perineum  becomes 
gangrenous. 

This  affection  may  be  developed  slowly  and  insidiously  without  any 
local  or  general  symptoms,  and  exceptionally  its  onset  is  very  brusque 
and  its  course  rapid  and  destructive.  Gangrene  of  the  penis  is  first 
seen  as  a  deep-red  spot  of  varying  sizes  and  as  a  quite  extensive  bluish 
mottling  of  the  skin,  upon  which  there  may  be  bloody  blebs.  Sooner 
or  later  the  invaded  patch  becomes  of  a  purplish  color  and  full  sphace- 
lation is  then  distinctly  seen.  In  favorable  cases  a  line  of  demarcation 
is  formed  at  the  junction  of  the  morbid  and  healthy  areas,  and  under 
treatment  the  gangrenous  tissues  slough  away  or  are  removed. 

Gangrene  of  the  penis  is  observed  in  young  but  more  commonly  in 
elderly  subjects. 

In  some  cases  balanitis,  phimosis,  and  paraphimosis  seem  to  be  the 
starting-points  of  the  trouble ;  in  others,  chancroids  and  chancres  in 
prepuces  the  seat  of  phimosis,  and  large  warts  seated  under  a  phimotic 
gland,  are  the  causes  of  gangrene. 

Traumatisms,  such  as  severe  blows  and  compression  of  the  organ  by 
means  of  rings  and  bottles  and  by  self-inflicted  ligaturing  of  the  parts 
with  string,  are  sometimes  the  cause  of  gangrene  of  the  penis.  In 
some  rare  cases,  fracture  of  the  organ  and  torsion  of  it  while  erect  have 
been  known  to  be  followed  by  this  condition. 

Certain  systemic  conditions  seem  to  be  the  underlying  causes  of 
gangrene  of  the  penis.  These  are  diabetes,  Bright's  disease,  chronic 
alcoholism,  typhoid  and  typhus  fevers,  erysipelas,  intense  malaria,  small- 
pox, and  a  generally  vitiated  state  of  the  system.  In  all  such  cases  there 
is  usually  a  coexistent  balanitis,  and  it  is  probable  that  uncleanliness  is 
also  a  morbid  factor.  Cases  have  been  reported  in  which  gangrene  of 
the  penis  was  said  to  be  due  to  the  ingestion  of  ergot  and  cantharides, 
and  in  one  it  was  claimed  that  atheroma  of  the  arteries  of  the  penis 
was  the  essential  cause.  In  some  cases,  however,  it  is  impossible  to 
fix  definitely  upon  any  cause  which  has  so  disturbed  the  circulation  that 
gangrene  has  resulted. 


CANCER.  275 

Prognosis. — No  general  statement  as  to  prognosis  can  be  made.  In 
the  class  of  cases  in  which  the  lesion  is  due  to  affections  of  the  prepuce 
the  destructive  action  may  be  promptly  checked  by  appropriate  treat- 
ment. In  all  patients  suffering  from  infectious,  adynamic,  and  chronic 
diseases  a  guarded  prognosis  must  be  given. 

Treatment. — Gangrene  of  the  prepuce  must  be  treated  on  the  lines 
laid  down  for  the  management  of  phimosis  and  paraphimosis  (see  pages 
230,  237).  Sufficiently  deep  incisions  should  be  made  in  the  tense  parts 
to  relieve  the  circulation,  and  this  operation  should  be  followed  by  fre- 
quent and  copious  irrigations  with  hot  concentrated  boric  solution  or 
sublimate  solution  (1  :  2000).  In  the  intervals  of  irrigation  the  parts 
may  be  enveloped  in  moist  bichloride  gauze.  Gangrenous  patches  and 
tabs  may  be  removed  by  means  of  the  scissors.  Iodoform  and  iodoform 
gauze  may  be  employed  when  the  morbid  process  shows  signs  of  abate- 
ment. 

It  is  necessary  to  sustain  the  weakened  vital  powers  and  to  improve 
the  nutrition  of  the  patient  by  good  food  and  tonics,  and  to  treat  all 
general  morbid  conditions  according  to  indications. 

When  the  gangrene  has  extended  to  the  perineum  (in  which  cases 
micturition  is  sometimes  interfered  with  and  cauterization  is  impossible) 
and  particularly  when  it  coexists  with  stricture  of  the  urethra,  external 
urethrotomy  should  be  promptly  performed. 

CANCER. 

Cancer  of  the  penis,  according  to  the  statistics  from  reliable  sources, 
stands  seventh  in  frequency  of  all  cancers  in  the  male  sex,  and  consti- 
tutes about  5  per  cent,  of  all  cancers  in  that  sex. 

In  the  greater  number  of  cases  cancer  of  the  penis  begins  on  the  pre- 
puce, in  a  rather  smaller  proportion  of  cases  on  the  glans,  sometimes  on 
glans  and  prepuce,  and,  again,  exceptionally,  on  the  cutaneous  sheath 
of  the  penis. 

Several  cases  have  been  reported  in  which  the  disease  began  in  the 
urethral  canal  a  few  inches  from  the  meatus  and  as  far  down  as  the  bulb. 

It  sometimes  happens  that  cancer  of  the  penis  occurs  from  extension 
of  the  disease  from  the  scrotum. 

Etiology. — Besides  that  unknown  factor — tissue-susceptibility  or 
predisposition — and  certain  unknown  conditions  (in  the  majority  of 
cases)  incident  to  age,  chronic  irritation  seems  to  be  the  chief  cause  of 
cancer  of  the  penis.  Since  phimosis  is  a  frequent  cause  of  chronic  bal- 
anitis in  which  the  irritative  process  is  active,  this  condition  takes  a 
prominent  place  in  the  etiology  of  penis-cancer.  This  form  of  new- 
growth,  however,  is  not  at  all  confined  to  cases  of  phimosis,  but  is  seen 
in  persons  with  normally  roomy  prepuces,  and  quite  rarely  in  those  having 


276  AFFECTIONS  OF  THE  PENIS. 

little  if  any  prepuce.  In  all  probability,  the  personal  habits  of  the 
man  in  very  many  cases  have  much  to  do  with  the  development  of  can- 
cer of  the  penis.  When  the  organ  is  kept  clean  and  dry,  even  in  the 
aged,  it  is  fair  to  suppose  that  cancer  will  not  attack  it.  On  the  other 
hand,  uncleanliness,  with  the  resulting  harboring  of  decomposed  secre- 
tions and  of  dirt,  tends  to  cause  a  chronic  irritative  process  which  may 
(the  condition  of  the  patient's  system  favoring  it)  eventuate  in  malignant 
degeneration.  The  occurrence  in  the  majority  of  instances  of  penis- 
cancer  in  men  of  the  lower  walks  of  life,  whose  care  of  the  person  is 
generally  very  scant,  seems  to  warrant  the  opinion  that  the  disease  is 
largelv  due  to  the  results  of  uncleanliness. 

Clinical  observation  has  shown  that  traumatism  is  occasionally  an 
exciting  cause. 

Syphilis  can  hardly  be  considered  other  than  as  a  very  exceptional 
etiological  factor  in  cancer  of  the  penis.  The  scars  of  chancroidal 
ulcers  may,  like  those  left  by  syphilitic  lesions,  cause  chronic  irritation 
which  may  lead  to  epithelioma. 

There  are  no  facts  at  hand  to  warrant  the  assumption  that  cancer  of 
the  penis  may  more  or  less  remotely  originate  in  heredity. 

The  subject  of  protozoa  as  appertaining  to  cancer  is  yet  so  vaguely 
understood  that  speculation  upon  it  is  deemed  inexpedient. 

Course  and  Symptoms. — In  many  cases  of  epithelioma  of  the  penis 
the  initial  symptoms  are  very  insignificant,  and  they  may  pass  unheeded, 
especially  by  patients  of  the  lower  walks  of  life.  Usually  intelligent 
subjects  give  a  history  of  a  mild  pruritus  or  of  a  slight  burning  sensa- 
tion at  the  date  of  onset  of  their  trouble.  The  truth  is,  that  the  condi- 
tion of  the  prepuce  and  the  habits  of  the  patient  have  much  to  do  with 
the  mildness  or  intensity  of  early  symptoms. 

In  some  cases  one  or  more  fissures  or  thickened  patches  appear  either 
in  the  mucous  layer  of  the  prepuce,  usually  the  seat  of  chronic  irrita- 
tion, or  at  its  free  margin  or  in  the  coronal  sulcus.  Then  chronic  rebel- 
lious ulceration  of  a  low  grade  appears,  and  the  parts  become  more  and 
more  hard  until  a  dense,  almost  ligneous,  patch  or  nodule  is  developed. 
From  this  starting-point  large  masses  of  indurated  tissue  develop,  which 
produce  exuberant  lesions  and  much  deformity.  In  these  cases  there  is 
no  evidence  of  warty  or  cauliflower  growth,  but  large,  irregular,  fleshy 
masses,  in  the  interstices  of  which  a  curdy,  smegma-like  layer,  besides 
pus  and  a  horribly  fetid  sanies,  are  secreted.  This  condition  is  well 
shown  in  Fig.  80,  which  represents  the  appearances  presented  by  a 
case  of  my  own  in  which  the  new  growths  formed  a  mass  as  large  as  a 
good-sized  orange. 

The  most  common  mode  of  origin  of  epithelioma  of  the  penis  is  in 
warty  growths,  which  may  promptly,  or  after  the  lapse  of  months  and 


CANCER. 


277 


even  years,  degenerate  into  epithelioma.  Such  is  the  liability  of  vege- 
tations to  undergo  degeneration  in  those  of  middle  age,  and  particularly 
in  elderly  persons,  be  they  weak  or  strong,  that  their  presence  should 
immediately  demand  at  the  hands  of  the  surgeon  prompt  removal  and 
treatment. 

Then,  again,  we  see  cases  in  which  the  patient  presents  a  little  nod- 
ule or  a  patch  of  hard,  warty  growth  on  the  penis,  looking  something 
like  the  seed-warts  seen  on  boys'  hands  and  knuckles.  He  complains 
of  little  if  any  discomfort,  perhaps  a  little  pruritus.     This  seemingly 

Fig.  80. 


Cancer  of  the  penis,  showing  very  large  fleshy  masses. 


insignificant  lesion  grows  slowly  and  in  a  cold  manner,  and  months 
and  even  several  years  may  elapse  before  it  reaches  such  a  size  as  to 
become  annoying.  Then  it  may  be  cut  out,  only  to  reappear  later  on  in 
the  cicatrix.  After  that,  amputation  of  the  penis  is  usually  performed. 
There  is  still  another,  but  rather  rare,  mode  of  invasion  and  devel- 
opment of  cancer  of  the  penis  of  which  I  have  seen  several  examples. 
In  middle  life  and  beyond,  patients  sometimes  consult  the  surgeon  for  a 
chronic  mildly  scaling  affection  of  the  glans  or  prepuce,  or  both.  The 
symptoms  attending  this  condition  are  usually  not  well  marked,  and 
they  may  consist  only  of  occasional  slight  heat  or  itching.  The  morbid 
areas  show  slight  thickening  of  the  tissues  and  a  constant  desquamation 
of  small  scales  or  even  lamellae.  This  affection  often  goes  on  in  the 
most  exasperating  manner  in  spite  of  well-directed  treatment,  and  even 
in  persons  whose  prepuce  is  short.  Having  existed  usually  several 
years,  the  thickening  of  the  tissues  becomes  greater,  and  then  the  new 
growth  more  or  less  rapidly  develops  and  forms  large  fleshy  masses. 


278  AFFECTIONS  OF  THE  PENIS. 

In  the  greater  number  of  cases  the  disease  is  localized  to  the  prepu- 
tial and  glandular  portion  of  the  penis.  The  corpora  cavernosa,  with 
their  firm  fibrous  structure,  offer  a  strong  barrier  to  the  cancerous  inva- 
sion, which  may  remain  intact  for  years.  Consequently,  there  is  a 
tendency  in  most  cases  to  the  localization  of  the  disease  to  the  distal 
portion  of  the  penis.  It  sometimes  develops  farther  up  the  organ,  its 
cells  having  been  carried  there  by  the  lymphatics.  It  is  rare  to  see 
involvement  of  the  whole  organ  by  cancer  in  the  primary  attack.  But 
extension  may  occur  by  means  of  the  corpus  spongiosum,  in  which  case 
the  whole  organ  may  be  later  on  involved.  Recurrence  of  the  cancer  in 
the  stump  often  leads  to  its  full  involvement,  the  corpora  cavernosa  no 
longer  acting  as  a  barrier. 

A  most  annoying  complication  is  the  low  grade  of  ulcerative  process 
which  goes  on  in  the  interstices  of  the  masses  and  on  its  surface,  and 
produces  a  horribly  fetid  secretion,  rendering  the  patient  an  object  of 
disgust  to  himself  and  those  with  whom  he  comes  in  contact. 

With  the  development  of  the  cancerous  growth  pain  may  become  a 
very  serious  symptom.  Owing  to  compression  of  the  urethra,  urination 
often  becomes  very  difficult  and  painful.  Hemorrhage  of  greater  or 
less  severity  is  a  quite  frequent  concomitant. 

With  the  full  development  of  the  disease,  profound  cachexia  and 
wasting  are  developed,  which  in  the  end  carry  off  the  patient. 

Invasion  of  the  Ganglia. — For  a  greater  or  less  length  of  time 
the  inguinal  ganglia  seemingly  remain  unaffected.  We  have  no  reliable 
statistics,  however,  showing  the  date  at  which  cancer  attacks  these 
structures.  In  most  cases  the  patient  is  seen  late  in  this  affection,  and 
then  the  ganglia  are  found  to  be  attacked.  As  a  general  rule,  the 
ganglia  are  affected  on  both  sides,  and  only  on  one  side  in  about  one- 
third  of  all  cases. 

When  affected  by  cancer  the  ganglia  of  the  groin  and  also  of  the 
thigh  become  hard,  smoothly  enlarged,  separable  from  each  other,  and 
movable  under  the  skin.  They  may  remain  thus  for  months  or  for 
several  years.  Then,  again,  exuberant  cancerous  development  may 
take  place  in  them,  and  they  may  become  transformed  into  large  round, 
oval,  or  lobulated  tumors.  This  cancerous  mass  may  remain  unchanged, 
but  it  usually  causes  ulceration  of  the  overlying  skin.  Owing  to  the 
proximity  to  the  femoral  vessels,  mild  or  severe  hemorrhages  are  liable 
to  occur  from  erosion  of  their  walls  by  the  cancerous  growth. 

A  second  order  of  phenomena  may  occur  in  these  cancerous  buboes. 
The  glands  more  or  less  promptly  undergo  acute  inflammation,  suppura- 
tion ensues,  and  the  pus  either  forces  an  outlet  or  is  evacuated  by  the 
knife.  In  most  cases  the  morbid  process  does  not  stop  with  the  destruc- 
tion of  the  glands.     The  connective  tissue  and  the  skin  become  the  seat 


CANCER.  279 

of  secondary  infection,  and  there  is  then  produced  a  formidable  cancer 
in  the  groin. 

Strange  as  it  may  seem,  tertiary  metastasis  from  the  secondary  groin- 
cancer  is  the  exception  rather  than  the  rule.  It  is  rare  to  see  general 
diffusion  of  malignancy  in  cancer  of  the  penis. 

The  involvement  of  the  inguinal  ganglia  in  epithelioma  of  the  penis 
is  inevitably  followed  by  death  at  an  early  or  late  date. 

Diagnosis. — The  diagnosis  of  cancer  of  the  penis  may  be  difficult  in 
the  early  stages  of  the  growth.  The  existence  of  chronic  or  oft-recur- 
ring irritation  of  the  glans  or  prepuce,  folloAved  by  a  localized  warty 
growth  or  indurated  exulcerated  patch  or  nodule,  should  always  excite 
a  suspicion  of  cancer,  particularly  in  elderly  men,  and  more  especially 
when  the  existence  of  syphilis  has  been  excluded.  Then,  again,  the 
behavior  of  the  lesion  under  treatment  may  give  a  clue  as  to  its  nature, 
for  simple  processes  are  usually  amenable  to  proper  management,  while 
the  malignant  forms  go  on  unchecked  and  uncured.  Constant  exami- 
nation of  the  lymphatic  ganglia  is  necessary,  since  their  enlargement 
under  these  circumstances  will  frequently  lead  to  a  correct  diagnosis  of 
cancer.  Portions  of  the  growth  should  be  examined  with  the  micro- 
scope as  early  as  possible. 

When  seen,  as  most  cases  are,  late  in  the  development  of  cancer 
of  the  penis,  its  diagnosis  is  usually  very  easy.  The  large,  fleshy,  hard 
masses,  their  fungating  appearance,  the  distortion  produced,  and  the 
fetid  secretion,  all  point  to  cancer  of  the  penis. 

Prognosis. — This  depends  upon  the  time  at  which  the  cancer  is  seen 
and  its  nature  recognized.  If  seen  early  and  the  growth  is  small  and 
favorably  situated  for  removal,  its  ablation  may  give  to  the  patient 
future  immunity.  If  the  new-growth  is  very  large  and  if  it  has 
existed  for  several  years,  the  prognosis  is  less  favorable.  In  any  case 
the  condition  of  the  inguinal  lymphatic  ganglia  gives  the  most  reliable 
prognostic  data.  If  the  glands  are  but  slightly  enlarged  and  show  an 
indolent  tendency,  a  year  or  many  years  may  elapse  before  a  fatal  termi- 
nation results. 

Cancer  of  the  penis  is  so  well  localized  and  so  sharply  limited  in 
many  cases  that  the  conditions  for  its  removal  and  extirpation  are  more 
favorable  than  upon  other  regions.  Still,  the  sad  fact  stares  us  in  the 
face  that  in  the  vast  majority  of  cases  cancer  of  the  penis  almost  inev- 
itably leads  to  death. 

Recurrence  of  this  disease  in  the  stump  is  not  uncommonly  seen. 
Statistics  on  this  point,  however,  are  not  sufficiently  clear  and  reliable. 
This  accident  probably  occurs  in  about  25  per  cent,  of  all  cases. 

Pathological  Anatomy. — Cancer  of  the  penis  is  of  the  epithelioma- 


280  AFFECTIONS  OF  THE  PENIS. 

tous  variety,  being  the  ordinary  skin-cancer  involving  squamous  epi- 
thelium. 

Treatment. — According  to  the  severity  of  the  case  amputation  or 
extirpation  of  the  penis  may  be  necessary. 

Too  much  cannot  be  said  in  favor  of  an  early  and  radical  operation 
in  cases  of  cancer  of  the  penis,  since  such  a  course  gives  the  patient  a 
much  greater  immunity  to  subsequent  trouble. 

Amputation  of  the  Penis. 

The  patient  having  been  prepared  for  the  operation,  is  placed  on  his 
back  and  a  soft-rubber  catheter  is  quite  firmly  tied  around  the  root  of 
the  penis,  in  order  to  control  hemorrhage.  Then  two  long  bonnet-pins 
are  thrust  through  the  corpora  cavernosa,  sufficiently  well  behind  the 
tumor  on  each  side,  in  an  X-like  manner,  avoiding  the  corpus  spongio- 
sum. Before  inserting  the  pins  it  is  necessary  to  manoeuvre  and  ma- 
nipulate a  little,  so  as  to  get  the  body  of  the  penis  back  about  three- 
quarters  of  an  inch  and  to  slide  the  integumentary  sheath  correspond- 
ingly forward.  Then,  traction  being  made  from  the  distal  and  diseased 
portion  of  the  penis  with  the  left  hand  or  by  the  aid  of  an  assistant, 
extension  and  steadiness  are  afforded,  and  a  circular  incision  is  made 
through  the  integument  at  the  distal  portion  of  the  penis,  taking  care 
not  to  cut  the  corpus  spongiosum.  Then  the  corpora  cavernosa  are  cut 
through  downward  until  the  corpus  spongiosum  is  reached.  This  struc- 
ture should  be  carefully  dissected  out,  and  fully  one-half  or  three- 
quarters  of  an  inch  should  be  left  to  protrude  beyond  the  amputated 
end  of  the  corpora  cavernosa.  We  then  have  the  latter  structures  as 
the  stump  proper ;  around  it  is  the  ring  of  integument  fully  three- 
quarters  of  an  inch  longer  than  it,  and  underneath  the  corpus  spongio- 
sum is  intact  and  fully  half  an  inch  longer  than  the  stump.  At  this 
time  the  compression  is  moderately  relaxed,  and  all  oozing  or  spurting 
vessels  are  clamped  and  ligated,  one  by  one,  with  gut.  The  next  step  is 
the  formation  of  the  urethral  orifice.  In  this  procedure  we  should  be 
guided  by  our  knowledge  of  anatomy.  If  only  one  or  two,  or  even  three 
inches  of  the  penis  are  removed,  the  incision  into  the  corpus  spongiosum, 
which  should  be  made  with  scissors,  should  be  vertical,  for  the  reason 
that  thus  far  the  urethra  is  a  vertical  slit.  Farther  down,  where  the 
urethra  is  a  transverse  slit,  the  incision  should  be  transverse.  In  the 
first  case  we  have  vertical,  and  in  the  second  horizontal  or  transverse 
flaps.  Then  the  tegumentary  ring  should  be  stitched  to  the  margins 
of  the  corpora  cavernosa  by  means  of  close  interrupted  silk  sutures, 
leaving  the  formation  of  the  urethra  to  the  last.  Then  both  flaps  of 
the  corpus  spongiosum  must  be  stitched  with  silk,  in  case  they  are  verti- 
cal, to  the  corpora  cavernosa,  and  if  horizontal  the  upper  one  should  be 


EXTIRPATION  OF  THE  PENIS.  281 

stitched  to  those  structures  and  the  lower  one  to  the  integument.  The 
wound  is  dressed  with  iodoform  and  surrounded  by  sterilized  gauze 
kept  in  place  by  means  of  a  T-bandage.  A  soft  rubber  catheter  may 
be  retained  in  the  urethra  for  a  few  days,  or  the  urine  may  be  drawn 
off  by  means  of  such  a  catheter  of  a  calibre  of  about  No.  10  French. 
It  is  well  for  a  time  to  use  suppositories  of  morphine  to  control  erections. 

The  patient  will  be  confined  to  his  bed  for  about  three  weeks.  As 
healing  takes  place  in  the  stump  it  is  well  to  watch  the  new  urethral 
orifice  carefully,  and,  if  necessary,  to  introduce  every  few  days  a  soft 
olivary  bougie  (20  F.).  As  a  result  of  this  operation  a  good  stump  is 
left.  There  is  a  redundance  of  integument  beyond  the  ends  of  the 
corpora  cavernosa  which  will  admit  of  erection  of  the  latter  without 
pain  or  inconvenience.  In  many  such  cases  coitus  is  possible  after  the 
operation. 

The  patient  whose  penis  has  been  amputated  should  report  to  the 
surgeon  from  time  to  time,  in  order  that  he  may  see  that  the  urethra 
remains  patulous.  Should  it  be  necessary,  by  reason  of  contraction,  the 
systematic  introduction  of  an  olivary  bougie  into  the  urethra  may  be 
made  every  few  days  or  a  week  for  a  longer  or  shorter  period. 

Extirpation  of  the  Penis. 

This  is  accomplished  in  the  following  manner  :  The  scrotum  should 
be  split  into  two  halves  in  the  whole  length  of  the  line  of  the  raphe, 
back  to  the  corpus  spongiosum.  A  good  sized  metal  catheter  or  sound 
should  then  be  passed  as  far  as  the  triangular  ligament,  and  the  knife 
inserted  between  the  corpora  cavernosa  and  corpus  spongiosum.  The 
latter  structure  is  carefully  separated  as  far  back  as  the  triangular 
ligament  if  necessary — at  any  rate,  well  behind  the  disease.  The  sound 
is  then  withdrawn,  the  urethra  cut  across,  and  carefully  dissected  out. 
In  the  course  of  the  operation  the  arteries  of  the  corpora  cavernosa  and 
the  dorsal  artery  of  the  penis  are  divided,  and  it  is  necessary  to  ligate 
them.  Then  an  incision  is  made  around  the  root  of  the  penis  on  each 
side  up  to  the  central  incision  below.  The  suspensory  ligament  is  then 
cut  through,  and  the  crura  of  the  corpora  cavernosa  are  detached  from 
the  rami  of  the  pubes  by  means  of  the  periosteal  elevator.  If  the  bone 
is  involved,  resection  must  be  performed.  The  urethra  is  now  brought 
out,  slit  up  vertically,  and  stitched  to  the  lower  angle  of  the  wound  in 
the  scrotum.  If  the  testicles  have  also  been  removed,  with  the  purpose 
of  obliterating  sexual  desire,  the  urethra  is  stitched  to  the  lower  angle 
of  the  perineal  wound.  The  after-treatment  requires  the  observance  of 
rigid  antisepsis,  the  frequent  renewal  of  dressings,  and  the  withdrawal 
of  the  urine  with  a  small  soft-rubber  catheter. 


282  AFFECTIONS  OF  THE  PENIS. 

Extirpation  of  the  Ganglia. 

In  every  case  of  cancer  of  the  penis  the  inguinal,  and  perhaps  the 
femoral,  ganglia  should  be  thoroughly  removed,  preferably  at  the  time 
of  amputation  of  the  organ,  or  a  little  later  on  if  such  delay  is  impera- 
tive. The  dissection  should  be  most  thorough,  and  care  should  be  taken 
not  to  wound  the  femoral  vessels,  the  anterior  crural  nerve,  and  the 
saphena  vein. 

Sarcoma. 

This  form  of  malignant  degeneration  of  the  penis  is  usually  second- 
ary to  the  involvement  of  other  parts;  it  may,  however,  be  primary. 
As  a  rule,  it  begins  in  the  tissues  of  the  corpora  cavernosa. 

This  new-growth  attacks  both  young  and  old,  and  sometimes  seems 
to  follow  traumatisms.  The  clinical  features  are  the  slow,  and  some- 
times rapid,  development  of  a  tumor  without  any  painful  sensations, 
which  enlarges  and  distorts  the  penis.  After  removal  there  is  always 
great  danger  of  the  return  of  the  morbid  process. 

Secondary  sarcomata  of  the  penis  are  sufficiently  common,  and  they 
present,  in  the  main,  symptoms  similar  to  those  of  the  primary  variety. 

The  treatment  is  the  same  as  that  recommended  for  epithelioma. 

Hypospadias. 

This  condition  consists  in  a  greater  or  less  congenital  deficiency 
of  the  corpus  spongiosum  and  of  the  urethra.  When  the  urethra 
ends  at  the  base  of  the  glans  the  condition  is  called  balanic  hypos- 
padias, and  when  it  ends  in  the  course  of  the  penis  between  the 
glans  and  the  penoscrotal  angle  it  is  called  penile  hypospadias.  A 
third  and  exceedingly  rare  form  of  this  affection  is  known  as  scrotal  or 
perineoscrotal  hypospadias,  in  which  the  orifice  of  the  urethra  is  found 
in  the  scrotal  sulcus  (which  may  have  the  form  of  a  cleft  like  a  vulva) 
or  in  the  perineum.  It  is  very  rare  to  find  congenital  defects  in  the 
membranous  and  prostatic  urethra,  consequently  in  all  cases  of  hypos- 
padias the  patient  has  control  of  his  urine.  In  balanic  hypospadias  the 
patient  usually  ejects  the  urine  in  a  normal  manner,  but  in  propor- 
tion as  the  urethral  orifice  is  situated  further  back  in  the  penis 
the  stream  is  weak,  and  the  patient  wets  his  under-linen  unless  he 
urinates  in  the  sitting  posture. 

Treatment. — Balanic  hypospadias  usually  requires  no  surgical  opera- 
tion except  perhaps  when  the  urethral  orifice  is  small,  and  then  a  slight 
incision  followed  by  dilatation  will  relieve  the  parts.  In  most  cases  of 
penile  hypospadias  the  functions  of  the  penis  are  not  materially  im- 
paired, hence  operative  measures  are  not  necessary.     In  some  of  these 


EPISPADIAS  283 

cases  the  shortened  urethra  acts  like  the  string  to  a  bow,  and  it  is  then 
necessary  (using  thorough  antisepsis)  to  dessect  the  canal  out  and  to 
suture  it  further  back  in  the  penis,  and  thus  relieve  the  parts  of  the  in- 
cur vating  tension.  Plastic  operations  designed  to  restore  the  length  of 
the  urethra  cannot  be  given  in  full  detail,  since  the  condition  of  the 
parts  varies  in  different  cases.  In  all  these  operations  the  surgeon 
must  adapt  the  incisions  according  to  the  indications  presented  to  him. 
All  cases,  as  a  rule,  require  several  operations,  and  in  very  many  more 
or  less  complete  failure  is  experienced. 

In  cases  of  scrotal  and  perineoscrotal  hypospadias  it  is  necessary  to 
perform  perineal  urethrotomy  first  and  thus  gain  a  bladder-drain,  then 
by  dissection  and  plastic  operations  the  deficiency  in  the  urethra  may 
be  restored.  It  is  always  well  in  these  cases  not  to  hold  out  to  the 
patient  very  sanguine  hopes. 

Epispadias. 

In  this  severe  and  exceedingly  rare  form  of  malformation  the  urethra 
opens  on  the  upper  surface  of  an  imperfect  penis  either  in  its  glandular 
portion  in  the  continuity  of  the  organ  or  at  the  symphysis  pubis,  in 
which  event  there  is  usually  ectopia  vesicae. 

Treatment. — Cases  of  epispadias  are  so  rare  that  they  may  be 
called  surgical  curiosities,  and  more  or  less  complete  failure  to  remedy 
the  malformation  is  the  rule  rather  than  the  exception.  When  he  has 
decided  to  operate,  the  surgeon  has  his  choice  between  the  method  of 
Dolbeau  and  that  of  Thiersch,  which  procedures  have  in  some  instances 
been  followed  by  tolerably  fair  results. 


CHAPTER   XII. 

AFFECTIONS  OF  THE  SCROTUM. 

Contusions  and  wounds  of  the  scrotum,  if  of  a  severe  nature,  are 
usually  associated  with  more  or  less  injury  to  the  testicle,  and  therefore 
require  proper  support  and  the  usual  surgical  treatment  employed  for 
traumatisms  and  wounds  in  general.  If  the  tunica  vaginalis  has  been 
opened,  the  greatest  care  must  be  exercised  in  regard  to  cleanliness,  as 
suppuration  of  that  cavity  may  be  followed  by  destruction  of  the 
testicle. 

The  scrotum  may  be  attacked  by  almost  any  of  the  various  skin 
diseases  which  affect  other  portions  of  the  integument,  so  for  a  descrip- 
tion of  them  and  their  treatment  the  reader  is  referred  to  works  on 
dermatology. 

(Edema. — True  oedema,  or  dropsical  effusion  of  the  scrotum,  is  some- 
times observed  as  a  manifestation  of  certain  renal  and  cardiac  affections, 
and  also  after  the  too  radical  removal  of  the  inguinal  glands  for  sup- 
purative adenitis,  malignant  disease,  or  tubercular  affections. 

The  treatment  of  oedema  depends  upon  the  cause,  which,  if  possible, 
must  be  removed.  The  scrotum  should  be  properly  elevated,  and  the 
serum  evacuated  either  by  massage  and  pressure,  or  by  multiple 
punctures,  made  with  all  antiseptic  precautions. 

Emphysema  of  the  scrotum  is  sometimes  observed  in  cases  of 
urinary  scrotal  extravasation,  when  it  is  due  to  the  liberation  of  gas 
from  the  sloughing  tissues,  the  etiological  factor  being  a  septic  urine, 
while  sterile  urine,  as  has  been  shown  experimentally,  can  be  injected 
into  the  tissues  with  impunity. 

A  certain  amount  of  air  may  enter  the  loose  scrotal  tissues  in  wounds 
or  injuries  of  these  parts,  and  air  or  gas  may  sometimes  find  its  way 
there  from  distant  wounds  which  communicate  either  with  the  air 
passages  or  the  intestines. 

Treatment. — By  free  incisions  all  of  the  gas,  with  decomposing 
urine  and  sloughing  tissues,  must  be  liberated  immediately  and  the 
parts  cleansed  with  peroxide  of  hydrogen  and  hot  saline  solution,  and 
dressed  in  the  usual  manner ;  the  cause  of  the  extravasation  being 
removed  at  the  same  time.  (See  Extravasation  of  Urine  due  to  Stricture.) 
Air,  or  even  gas,  may  be  absorbed  spontaneously  by  the  tissues,  or 

284 


PLATE   V. 


SEBACEOUS  CYSTS  (WENS)  OF  THE  SCROTUAA. 


AFFECTIONS  OF  THE  SCROTUM.  285 

may  require  a  few  punctures  or  incisions,  followed  by  a  light  pro- 
tective dressing. 

Gangrene. — Gangrene  of  the  scrotum  may  follow  traumatism  or 
extravasation  of  urine,  and  may  also  occur  spontaneously  without 
apparent  cause.  In  this  latter  form  the  destruction  of  tissue  may  be 
slight  or  so  extensive  that  the  testes  are  left  exposed,  the  necrotic  proc- 
ess involving  the  penis  to  a  greater  or  less  degree.  This  form  of  gan- 
grene is  usually  encountered  in  alcoholic,  debilitated,  and  generally  run- 
down and  poorly  nourished  subjects  affected  with  B right's  disease  and 
diabetes,  such  as  are  seen  mostly  in  hospital  practice. 

Treatment. — The  patient's  general  condition  must  be  improved  by 
a  nourishing  diet,  tonics,  fresh  air,  and  attention  to  the  bowels.  The 
scrotum  should  be  properly  supported  and  kept  scrupulously  clean  and 
moist  with  saline  gauze,  over  which  is  placed  a  layer  of  oiled  silk.  As 
the  line  of  demarcation  forms,  the  gangrenous  tissues  are  removed  and 
the  subjacent  parts  cleansed.  In  this  manner  it  is  surprising  to  see  how 
the  great  loss  of  tissue  is  replaced  by  granulations  which  in  time  cover 
over  the  exposed  testes. 

Elephantiasis  of  the  scrotum  will  be  found  fully  described  on  page 
254,  with  elephantiasis  of  the  genitals. 

Tumors. — The  scrotum  may  be  the  seat  of  cysts,  sebaceous  cysts 
(see  Plate  V.),  fatty  tumors,  fibroma,  sarcoma,  and  epithelioma,  the  latter 
being  known  as  "  chimney-sweeps'  cancer,"  on  account  of  its  frequent 
occurrence  in  that  class  of  workers  and  probably  caused  in  them  by  the 
irritation  of  soot.  It  usually  begins  as  a  small  spot  of  localized  indura- 
tion, which  in  a  short  time  is  transformed  into  an  unhealthy-looking 
ulcer,  with  a  thin,  watery,  and  foul  secretion. 

Treatment. — Benign  growths  may  remain  for  years  in  the  scrotal 
tissues  without  causing  any  trouble  whatsoever,  but  it  is  always  best  to 
remove  such  tumors,  no  matter  what  their  nature  is  or  how  trifling  they 
may  appear.  Malignant  tumors  should  be  very  radically  removed, 
together  with  the  adjacent  lymphatic  glands. 


CHAPTEK    XIII. 

AFFECTIONS  OF  THE  URETHRA. 

URETHRAL  CALCULI. 

Occasionally  one  or  more  calculi  are  found  in  the  urethra,  situ- 
ated within  its  bulbous,  pendulous,  or  prostatic  portion,  just  at  the 
peno-scrotal  angle,  or  in  the  fossa  navicularis.  They  usually  have 
their  origin  in  the  kidney  as  uric  acid  concretions,  which,  coming  down 
the  urinary  tract,  become  impacted  in  the  urethra,  and  incrusted  and 
increased  in  size  by  the  addition  of  phosphate  of  lime.  They  may 
attain  such  dimensions  as  more  or  less  completely  to  block  up  or  occlude 
the  urethral  canal,  thus  interfering  with  normal  urination  or  ejaculation, 
which  calls  the  patient's  attention  to  their  presence. 

Diagnosis. — Urethral  calculi  may  be  felt  from  without  by  palpating 
the  under  surface  of  the  penis.  A  metal  instrument  which  is  passed 
through  the  meatus  will  be  stopped,  or  will  give  a  grating  sensation 
as  it  passes  along.  The  endoscope  may  be  used  in  the  examination  of 
these  cases. 

Treatment. — Under  local  or  general  anaesthesia  calculi,  as  a  rule, 
can  be  removed  with  a  very  small  and  delicate  lithotrite,  or  straight  or 
curved  urethral  forceps.  If,  however,  this  proves  unsuccessful,  a  small 
opening  will  have  to  be  made  in  the  bulbous  portion  of  the  canal  and 
the  stone  removed  through  the  wound,  which  is  to  be  carefully  sutured 
around  a  medium-sized  soft-rubber  catheter,  which  should  drain  the  blad- 
der until  the  urethral  opening  is  completely  cicatrized.  A  stone  in  the 
prostatic  urethra  can  sometimes  be  pushed  back  into  the  bladder  with 
a  full-sized  sound,  and  when  there  grasped  with  a  small  lithotrite  and 
removed  en  masse,  or  crushed  and  evacuated  as  in  litholapaxy. 

FOREIGN  BODIES  IN  THE  URETHRA. 

Foreign  bodies  gain  access  to  the  urethra  either  as  the  result  of 
accident,  due  to  the  breaking  of  catheters  and  urethral  instruments,  or 
they  are  introduced  purposely  for  abnormal  sexual  gratification  by 
persons  who  are  sexually  degenerate,  these  unfortunates  introducing 
every  conceivable  article  that  will  pass  the  meatus. 

286 


AFFECTIONS  OF  THE    URETHRA.  287 

The  symptoms  are  those  of  obstruction  to  urination  and  ejaculation, 
and  the  treatment  is  exactly  the  same  as  that  just  given  for  the  removal 
of  urethral  calculi,  and  to  which  the  reader  is  referred. 

(For  a  further  consideration  of  affections  of  the  urethra  the  reader  is 
referred  to  the  chapters  on  Gonorrhoea  (pp.  17  et  seq.)  and  to  the  chap- 
ter on  Stricture  of  the  Urethra  (pp.  172  et  seq.). 


CHAPTER   XIV. 

AFFECTIONS  OF  THE  PROSTATE. 

Chronic  inflammation  of  the  prostate  is  induced  by  various  causes, 
the  most  frequent  probably  being  acute  and  chronic  gonorrhoea,  the 
next  in  order  being  masturbation  and  sexual  excesses.  It  may  also  be 
due  to  violence  with  sounds,  catheters,  and  litholapaxy  instruments,  to 
the  irritation  of  a  stone  in  the  bladder  or  of  a  fragment  of  stone,  or  of 
small  stones  impacted  in  its  mucous  membrane,  and  to  stricture.  It  is 
not  very  probable,  as  claimed  by  some,  that  injections  used  by  patients 
in  the  anterior  urethra  may  cause  inflammation  of  the  prostate,  but  very 
caustic  deep  injections  may  be  the  starting-point  of  the  trouble.  (For 
the  description  of  chronic  gonorrhoea!  congestion  and  abscess  of  the  pros- 
tate, see  pp.  98  et  seq.) 

CHRONIC   INFLAMMATION   OF   THE   VERUMONTANUM 
AND   PROSTATIC   URETHRA. 

This  form  of  chronic  prostatitis  is  not  very  uncommon,  and  is  found, 
as  a  rule,  in  men  from  about  eighteen  to  twenty-five  years  of  age.  The 
underlying  causes  are  either  prolonged  masturbation  or,  rather  less 
frequently,  chronic  posterior  urethritis ;  or  both  may  be  factors. 
Patients  thus  afflicted  may  enjoy  tolerably  good  health,  or  they 
may  be    ansemic  or  even   neurasthenic. 

The  first  symptoms  pointing  to  this  prostatic  disorder  are  referable 
to  the  sexual  system.  In  those  patients  who  indulge  in  coitus  it  is 
first  noticed  that  they  suffer  from  premature  ejaculations.  Erections 
may  be  firm  and  desire  may  be  great,  but  the  sexual  act  is  aborted. 
Then,  as  time  goes  on,  the  erections  become  less  vigorous  and  the  ejacu- 
lations are  weak  and  dribbling.  Unless  relieved,  such  patients  become 
impotent.  Besides  these  symptoms  nocturnal  pollutions  may  trouble 
the  patient,  Avho  may  also  observe  the  escape  of  mucus  from  the  urethra 
after  urination  or  defecation.  In  some  cases  a  feeling  of  weakness  and 
depression  follows  the  supposed  loss  of  semen.  All  these  symptoms 
may  be  observed  in  those  whose  trouble  originated  from  masturbation. 

When  the  emission  or  ejaculation  is  examined  under  the  microscope 
it  is,  as  a  rule,  found  to  consist  of  mucus  and  granular  phosphates ;  but 
in  some  chronic  cases  immature  and  dead  spermatozoa  may  be  seen  in 
the  fluid,  together  with  cuboidal  cells,  pus,  and  perhaps  calcium  oxalate. 

288 


CHRONIC  INFLAMMATION  OF  THE   VERUMONTANUM,   ETC.   289 

When  the  urine  is  examined,  if  posterior  urethritis  exists,  the  first 
few  ounces  will  contain  gonorrhoea!  threads,  the  second  specimen  will 
be  clear,  and  in  some  instances  the  third  specimen  will  have  a  decidedly 
milky  appearance,  due  to  the  mucus  and  granular  phosphates  which 
have  been  expressed  by  the  contraction  of  the  prostate.  If,  however, 
after  the  second  cylinder  has  been  filled  with  clear  urine  and  some  of 
the  residuum  is  still  left  in  the  bladder,  massage  of  the  prostate  will 
cause  a  more  or  less  copious  flow  (one-half  to  two  or  three  drachms)  of 
a  mucus  which  may  be  thin  and  milky  or  as  thick  as  condensed  milk. 
This  secretion  may  escape  from  the  meatus  or  it  may  be  voided  with 
the  urine.  In  any  event,  in  this  form  of  prostatitis  (and  the  same  is 
seen  in  other  forms)  the  dominating  component  parts  will  be  found 
to  be  mucus  and  granular  phosphates.  And  it  may  be  here  stated  that 
this  combination  is  the  one  which,  with  more  or  less  admixture  of 
other  crystals  and  of  tissue-elements,  will  be  found  throughout  the 
course  of  the  various  forms  of  prostatitis  yet  to  be  considered.  Some- 
times mucus  escapes  which  is  not  mixed  with  phosphates,  but  this  is 
not  of  frequent  occurrence.  It  is  most  important,  therefore,  that  the 
surgeon  should  become  thoroughly  familiar  with  the  appearance  of  this 
muco-phosphatic  secretion  and  with  the  urine  which  is  so  commonly 
voided  by  these  patients.  The  urine  is  usually  of  low  specific  gravity 
(1004  to  1010),  neutral,  moderately  alkaline,  or  not  very  acid  reaction. 
It  has  a  pale-straw  tint,  and  it  is  usually  voided  in  considerable  quanti- 
ties. Much  familiarity  with  these  cases  will  enable  the  surgeon  (if  he 
were  so  disposed)  to  make  a  diagnosis  simply  from  inspection  and 
microscopic  examination  of  the  urine.  As  has  been  said,  the  domi- 
nating feature  of  the  abnormal  discharge  is  the  combination  of  mucus 
and  granular  phosphates. 

These  patients  sooner  or  later  complain  of  frequent  urination  ;  in 
some  it  occurs  at  night,  in  others  in  the  daytime,  and  in  still  others 
both  during  the  day  and  at  night.  Some  patients  complain  of  pain  in 
the  passage  of  the  urine  as  if  it  scalded,  or  as  if  a  hot  iron  were  in  the 
canal,  and  it  is  not  uncommon  for  these  patients  to  experience  a  dull 
pain  in  the  glans  penis  at  the  end  of  urination.  Some  patients  have  a 
sensation  as  if  their  urine  escaped,  but  examination  of  the  penis  shows 
that  it  is  dry. 

Endoscopic  examinations  of  these  cases  should  not,  as  a  rule,  be  made, 
since  they  are  usually  very  painful,  and  the  conditions  which  they 
reveal  can  be  determined  by  other  and  less  severe  means.  The  facts 
already  developed  from  the  endoscopic  study  of  the  prostatic  urethra 
in  these  cases  show  very  clearly  that  the  whole  canal  is  very  red  and 
swollen,  and  this  is  observed  particularly  in  the  verumontanum  and 
the  adjacent  surfaces. 


290  AFFECTIONS  OF  THE  PROSTATE. 

Examination  of  these  cases  with  the  bougie  a  boule  shows  the  same 
state  of  affairs.  As  the  bulb  enters  the  prostatic  urethra  the  already 
apprehensive  patient  may  experience  a  severe  and  even  stabbing  pain, 
which  causes  him  to  cry  out,  particularly  as  it  glides  over  the  veru- 
montanum.  In  many  instances,  on  the  withdrawal  of  the  instrument 
a  little  blood  will  be  seen  on  the  bulb  or  at  the  meatus. 

In  some  cases,  when  the  steel  sound  is  introduced  there  may  be  some 
impediment  at  the  bulb,  due  to  spasm  of  the  compressor  urethra?  muscle. 
This,  however,  is  soon  and  painlessly  overcome,  and  then  the  tip  of  the 
instrument  passes  into  the  prostatic  urethra,  where  it  may  cause  at  first 
as  much  pain  as  the  bulb  does.  In  some  cases  a  powerful  spasm  of  the 
prostate  may  be  induced,  by  which  the  sound  is  ejected  from  the 
urethra,  or  an  orgasm  may  occur  and  the  same  result  is  produced. 
As  a  rule,  the  great  sensitiveness  of  the  deep  urethra  disappears  under 
careful  treatment,  and  the  introduction  of  the  sound  then  comes  to  be 
a  source  of  comfort. 

When  these  cases  are  further  examined  by  means  of  the  finger  in 
the  rectum  much  important  information  may  be  obtained.  Careful  pal- 
pation of  the  prostate  with  the  finger-tip  experiences  no  enlargement  or 
perceptible  change ;  indeed,  no  pain  may  be  produced  unless  deep 
pressure  be  made.  If,  however,  the  sound  is  left  in  the  urethra,  and 
then  pressure  by  the  finger-tip  in  the  rectum  is  made,  the  patient  may 
experience  pain,  and  even  cry  out  in  agony. 

By  this  study  of  the  symptomatology,  by  the  consideration  of  the 
antecedents  and  age  of  the  patient,  and  by  the  results  of  instrumental 
and  urinary  examination,  we  are  warranted  in  drawing  the  conclusion, 
which  has  been  largely  fortified  by  post-mortem  examinations,  that  such 
patients  are  suffering  from  exudative  catarrhal  inflammation  of  the 
mucous  membrane  of  the  prostatic  urethra,  and' that  the  verumontanum, 
with  its  numerous  contained  mucous  tubules  and  copious  nerve-  and 
blood-  supply,  is  the  focus  of  that  process.  This  condition,  which  is  now 
generally  vaguely  alluded  to  as  spermatorrhoea,  to  my  mind  is  a  distinct 
morbid  entity ;  and  it  may  exist,  I  am  positive,  without  any  extension 
or  involvement  of  the  environing  prostatic  substance  or  of  the  sexual 
parts  beyond.  Post-mortem  studies  have  clearly  proved  this  condition, 
which  can  readily  be  demonstrated  in  life  if  the  surgeon  has  sufficient 
experience  and  skill. 

This  affection,  as  it  becomes  very  chronic,  may  lead  to  catarrhal 
inflammation  of  the  gland-tubules. 

Prognosis. — As  a  rule,  these  cases  are  quite  promptly  benefited  by 
treatment,  provided  they  will  conform  to  the  requirements  of  sexual 
hygiene.  Sexual  and  alcoholic  excesses  prove  great  drawbacks  to  a  cure 
and  materially  interfere  with  the  treatment. 


CHRONIC  CATARRHAL   INFLAMMATION   OF  THE  PROSTATE.   291 

In  anaemic  and  neurasthenic  subjects  this  form  of  prostatitis  is  some- 
times very  chronic,  and  the  continuance  of  local  inflammation  leads  to 
the  intensification  of  the  general  low  condition.  In  many  cases,  how- 
ever, brilliant  results  follow  a  carefully  adapted  method  of  treatment. 

Treatment. — The  treatment  in  general  is  that  applicable  to  poste- 
rior urethritis.  The  health  and  morale  of  the  patient  should  be  im- 
proved as  much  as  possible  by  all  hygienic  influences.  In  anaemic  and 
neurasthenic  cases  iron,  quinine,  and  strychnine  are  very  beneficial,  and 
they  may  be  combined  with  coca  extract.  This  combination  will  be 
found  useful  in  most  cases  of  sexual  disorder  in  which  anaemia  or  neu- 
rasthenia coexists. 

But  in  all  these  cases  the  existence  of  the  focal  inflammation  delete- 
riously  reacts  on  the  sexual  centre  and  the  general  nervous  system,  and 
it  is  of  prime  importance  to  cure  that.  To  this  end  the  careful  intro- 
duction of  a  goodly  sized  (20  to  30  French  scale)  steel  sound  (chilled  in 
ice-water)  two  or  three  times  a  week,  and  its  retention  in  the  urethra  for 
three  or  four  minutes,  will  be  very  beneficial. 

Instillations  and  irrigations  of  nitrate  of  silver,  permanganate  of 
potassium,  or  of  alum  and  sulphate  of  zinc,  may  be  used  in  most  cases 
with  much  benefit. 

Constipation  should  be  avoided,  and  coffee,  liquors,  asparagus,  and 
spiced  dishes  should  not  be  indulged  in. 

Bromide  of  potassium,  belladonna,  and  hyoscyamus  may  be  used 
with  caution  to  meet  the  condition  of  erethism  when  it  arises. 

Prostatic  massage  is  not  indicated  in  these  cases. 

CHRONIC    CATARRHAL   INFLAMMATION   OF   THE 
PROSTATE. 

This  condition  is  not  very  uncommon,  and  in  order  to  understand 
it  fully  it  is  necessary  to  be  familiar  with  the  general  and  minute 
anatomy  of  the  prostate. 

In  some  cases  gonorrhoea  and  in  others  masturbation  is  the  primary 
cause.  The  essential  lesions  are,  first,  a  round-cell  infiltration  and 
hyperemia  in  the  connective  tissue  around  the  gland-tubules ;  and, 
second,  simple  catarrh  of  the  lining  membrane  of  the  gland-tubules. 
This  periglandular  inflammation  is  usually  continuous  with  that  of  the 
mucous  membrane  of  the  prostatic  urethra,  but  in  some  cases  this  latter 
condition  may  not  coexist,  or  it  may  be  only  an  insignificant  feature. 

Histological  investigations  have  shown  that  in  some  cases  of  inflam- 
mation of  the  prostatic  urethra  only  the  ducts  of  the  glands  have  been 
involved,  consequently  the  parenchyma  of  the  prostate  escaped.  It  has 
also  been  shown  that  one  or  more  groups  of  gland-tubules  may  be  at- 


292  AFFECTIONS  OF  THE  PROSTATE. 

tacked  in  an  irregularly  scattered  manner,  either  on  one  side  or  both, 
and  that  symmetrical  involvement  may  not  occur  in  one  or  in  both 
halves  of  the  prostate.  The  inflammatory  process  may  invade  in  an 
irregular  manner  several  groups  of  glands  on  one  or  both  sides  of  the 
organ,  and  there  may  be  scattered  here  and  there  groups  which  remain 
unaffected.  This  peculiarity  of  the  prostatic  inflammation  is  due  to  the 
anatomical  arrangement  of  the  tubules,  which,  in  passing  into  the  depths 
of  the  organ,  remain  separate  from  one  another.  Thus  it  happens  that 
the  inflammatory  process,  when  attacking  a  tubule  or  a  group  of  tubules, 
runs  down  them  to  their  blind  ends,  and  thus  limits  itself  and  shows 
no  tendency  to  invade  the  peripheral  parts.  In  some  cases  the  whole 
mass  of  gland-tubules  may  be  attacked.  This  knowledge  will  explain 
to  us  why  in  some  cases  the  whole  gland  is  swollen,  why  in  others  its 
surface  feels  nodulated  and  lumpy,  and  in  still  others  presents  the  sen- 
sation as  if  many  good-sized  shot  were  deeply  imbedded  in  the  capsule 
of  the  prostate.  In  the  first  case  the  glands  of  the  whole  organ  are 
quite  uniformly  attacked ;  in  the  second  groups  of  glands  are  swollen 
and  cause  nodulations  and  lumps  on  its  external  surface ;  and  in  the 
third  case  individual  glands  scattered  irregularly  over  the  organ  are  the 
seat  of  the  inflammation  which  by  its  limited  swelling  gives  the  finger 
the  sensation  as  if  shot  were  seated  in  the  tissues. 

Such  are  the  anatomo-pathological  facts  and  the  resulting  conditions 
which  are  revealed  to  the  surgeon  in  examining  cases  of  chronic  catarrh 
of  the  prostate. 

The  pathological  conditions  here  mentioned  may  lead  to  various 
secondary  morbid  states,  which  will  be  brought  out  later  on. 

Chronic  prostatitis  is  observed  in  the  period  between  puberty  and 
middle  age,  but  mostly  between  twenty  and  forty-five  years.  It  occurs 
in  all  classes,  in  the  poor  and  in  the  rich.  Though  the  morbid  condi- 
tions in  the  prostate  are  nearly  the  same  in  all  cases,  the  symptoms  pre- 
sented vary  very  considerably  in  different  cases.  This  marked  variation 
in  the  symptoms  allows  the  classification  into  certain  forms  of  the  dis- 
ease, the  description  of  which  will  lead  to  recognition. 

Temperament,  habits,  and  age  have  much  to  do  with  the  diversity 
of  the  symptoms  ;  but  in  the  chronic  course  of  the  disease  certain 
secondary  conditions  are  developed  and  certain  complications  may  be 
induced  which  also  give  rise  to  marked  symptoms.  Thus  in  many  cases 
the  symptom-complex  is  very  striking. 

Some  patients  suffering  from  chronic  prostatitis  experience  little 
trouble,  and  they  give  themselves  scarcely  any  concern  about  the  matter. 
Other  patients  may  be  troubled  more  or  less  in  mind,  but  their  health 
is  not  seriously  affected,  while  still  others  become  weak  and  nervous, 
and    even    truly    neurasthenic.     In   some    cases    prostatitis    causes    no 


CATARRHAL  PROSTATITIS  IN   YOUNG  SUBJECTS.  293 

symptoms,  or  if  present  they  are  unrecognized  until  some  failure  of  the 
health  occurs  from  dyspepsia,  mental  worry,  grip,  or  acute  adynamic 
diseases.  After  catching  cold,  standing  for  a  long  time  in  the  cold,  or 
sitting  on  cold  stones,  the  symptoms  of  chronic  prostatitis  have  first 
shown  themselves.  There  is  clear  evidence  at  hand  that  chronic  pros- 
tatitis has  lasted  many  years  (five  to  fifteen)  without  Jhaving  caused 
appreciable  symptoms,  and  its  existence  was  unsuspected  by  the  patient. 

Chronic  prostatitis  runs  a  long  and  irregular  course,  with  short  or 
long  periods  of  exacerbation  and  of  remission,  in  which  the  symptoms 
are  insignificant,  mild,  and  bearable. 

My  experience  and  study  have  convinced  me  that  the  most  correct 
and  satisfactory  division  of  chronic  prostatitis  is,  first,  that  form  which 
is  observed  in  patients  between  the  twentieth  and  thirtieth  years,  or 
thereabouts,  and,  second,  a  more  advanced  form,  which  is  seen  mostly 
in  patients  beyond  the  thirtieth  year.  This  division  is  not  at  all 
arbitrary,  but  is  based  upon  certain  quite  uniform  type-forms. 

Catarrhal  Prostatitis  in  Young  Subjects. 

The  symptoms  which  cause  patients  of  this  class  to  seek  relief  at  the 
hands  of  the  surgeon  may  be  arranged,  for  clearness  of  description, 
into  three  categories  :  first,  those  of  patients  who  complain  of  uneasiness 
in  the  prostate  and  perineum  and  rectum  ;  second,  those  of  patients  who, 
after  defecation,  urination,  and  severe  muscular  exertion,  notice  a 
mucous  discharge  from  the  penis ;  and,  third,  those  of  patients  who 
complain  of  ,some  form  of  sexual  weakness. 

In  some  of  these  cases  there  is  coexistent  inflammation  of  the  veru- 
montanum. 

Patients  who  complain  of  uneasiness  and  pain  in  the  prostate  are 
mostly  those  who  have  masturbated  immoderately,  or  whose  trouble 
began  in  specific  posterior  urethritis.  Very  often  the  symptom  is  so 
slight  that  it  causes  no  annoyance  or  impairment  of  health.  In  some 
cases  the  worry  and  fret  lead  to  anaemia,  and  in  severe  cases  neuras- 
thenia may  be  induced.  The  pain  or  uneasiness  may  be  continuous  or 
spasmodic,  or  it  may  only  be  felt  after  defecation,  urination,  and  severe 
bodily  exertion. 

Examination  of  the  prostate  by  means  of  the  finger  in  the  rectum 
shows  various  conditions,  as  follows :  the  whole  organ  may  be  a  little 
or  much  swollen  in  all  directions,  or  but  one-half  of  it  (and  usually 
it  is  the  left  one)  may  be  the  seat  of  the  congestive  infiltration. 
Moderate  or  severe  pain  may  be  produced  by  pressure,  or  such  may 
be  the  extreme  sensitiveness  of  the  gland  that  the  patient  will  not 
allow  it  to  be  touched.  Then,  again,  one  lump  or  many  of  them  may 
be  felt,  in  most  cases,  I  think,  limited  to  one  lobe,  and  in  a  smaller 


294  AFFECTIONS  OF  THE  PROSTATE. 

number  found  irregularly  scattered  in  both  lobes.  These  lumps  are 
more  or  less  painful.  And,  lastly,  there  may  be  found  scattered  over 
the  whole  prostate  half-pea-sized  or  large-shot-sized  prominences,  of 
which  there  may  be  two  or  three  or  even  a  goodly  number  seated  on 
one  or  both  lobes.  The  discovery  of  these  morbid  foci  clearly  war- 
rants the  diagnosis  of  chronic  prostatitis.  (In  some  cases  the  existence 
of  tuberculosis  may  "be  suspected.)  In  any  of  the  foregoing  conditions 
massage  of  the  prostate  will  cause  certain  abnormal  mucoid  secretions  to 
escape  from  the  meatus  or  to  appear  in  the  urine.  These  secretions  are 
as  follows :  1,  that  of  chronic  posterior  urethritis  ;  2,  a  clear,  viscid 
mucus ;  3,  mucus  and  cylindrical  prostatic  epithelium  ;  4,  mucus  (thin 
or  thick  and  viscid)  and  granular  phosphates  (this  is  the  secretion  most 
commonly  found);  5,  mucus,  granular  phosphates,  aud  cylindrical 
epithelium  (these  are  usually  found  in  very  recent  cases) ;  6,  mucus, 
granular  phosphates,  dead  and  puny  spermatozoa,  and  oxalate  of  lime ; 
and,  7,  mucus,  granular  phosphates  with  either  triple  phosphates  or 
crystalline  phosphate  of  lime.  In  any  of  these  secretions  there  may  be 
at  some  time  spermatozoa  and  pus  present. 

The  essential  secretion  of  all  chronic  catarrhal  prostatic  inflammation 
is  mucus  in  which  there  is  a  greater  or  less  admixture  of  granular 
phosphates.  This  secretion  in  excess  attests  the  activity  of  the  cylin- 
drical epithelial  cells  lining  the  tubules,  whose  function  in  health  is  to 
secrete  a  thin  milky  fluid,  together  with  the  granular  phosphates,  which 
constitute  the  true  prostatic  fluid  which  plays  such  an  important  role 
in  the  production  of  pure,  fertile  semen.  In  disease  this  normal  pro- 
cess becomes  exaggerated,  and  as  a  result  we  see  when  examining  cases 
of  catarrhal  prostatitis  the  clear  viscid  mucus,  the  milky  secretion,  and 
that  which  looks  as  it  escapes  from  the  meatus  like  a  wormy  mass  of 
condensed  milk.  When  the  prostatic  inflammation  becomes  still  more 
chronic  we  find  the  other  admixtures  which  have  just  been  enumerated. 
It  may  here  be  mentioned  and  emphasized  that  in  most  cases  of  chronic 
catarrhal  prostatitis  in  young  subjects  the  ejaculation  in  masturbation  is 
composed  mostly  of  the  above-mentioned  abnormal  prostatic  secretion, 
with  or  without  the  other  salts  or  spermatozoa.  Further,  it  is  well  to 
bear  in  mind  that  the  so-called  nocturnal  pollutions  in  these  cases,  the 
defecation  and  urination  ejaculate,  and  the  secretion  which  escapes  from 
the  urethra  after  hard  work,  are  all  wholly  or  nearly  composed  of 
mucus  and  granular  phosphates.  In  some  cases,  owing  to  causes  to  be 
mentioned  a  little  later,  some  spermatozoa  may  be  found  in  the  ejacu- 
late. With  this  statement  of  facts  held  well  in  mind  (which  I  have 
verified  in  clinical  observations  and  by  microscopic  studies  scores  of 
times),  the  vague  conception  of  that  old-time  bugbear  of  medicine — 
namely,  spermatorrhoea — really  becomes  an  enlightened  subject. 


CATARRHAL   PROSTATITIS  IN   YOUNG  SUBJECTS.  295 

In  some  of  these  cases  there  is  increased  frequency  of  urination 
during  the  day,  and  perhaps  during  the  night,  and  there  may  be  more 
or  less  uneasiness  or  pain  at  the  end  of  the  act.  In  some  cases  at  the  end 
of  urination  there  is  marked  tenesmus,  which  may  radiate  to  the  pelvis, 
rectum,  and  anus,  and  cause  much  distress  of  mind  and  suffering. 
These  patients,  besides  uttering  their  complaints  as  to  prostatic  pain 
and  soreness,  often  become  much  worried  and  nervous  about  their 
pollutions,  which  they  think  will  render  them  permanently  weak. 
Many  of  them  sooner  or  later  present  evidences  of  declining  sexual 
power. 

Unless  cured  by  proper  treatment  these  patients  continue  in  an 
unsatisfactory  state  for  months  and  years.  Some  may  appear  ruddy 
and  healthy,  even  though  they  suffer  somewhat,  and  worry  ;  others 
become  decidedly  nervous  and  anaemic,  while  not  a  few  really  become 
neurasthenic. 

In  proportion  as  the  mental  and  physical  reaction  is  severe,  so  is  the 
case  unpromising  as  to  ultimate  relief.  In  general,  with  the  improve- 
ment in  the  urethral  and  prostatic  trouble  which  proper  treatment 
brings  about,  the  mental  and  physical  condition  improves. 

Many  young  men  suffering  from  chronic  catarrhal  prostatitis  make 
no  complaint  of  symptoms  which  point  to  the  prostate  as  the  source  of 
their  trouble,  but  lay  much  stress  upon  their  so-called  loss  of  semen 
after  defecation  and  urination  and  bodily  exercise,  and  by  nocturnal 
pollutions.  In  these  patients,  as  a  rule,  we  find  by  rectal  examination 
all  the  tangible  conditions  of  the  prostate  already  mentioned,  and 
microscopic  examination  of  their  urine,  of  their  ejaculates,  or  of  the 
expressed  secretion  of  the  prostate  will  reveal  the  appearances  detailed 
in  the  preceding  pages.  This  class  of  patients  usually  become  very 
nervous  and  excited,  and  from  anaemia  rapidly  pass  into  a  neurasthenic 
condition,  and  complain  of  an  infinitude  of  morbid  symptoms.  They 
become  sexually  weak,  while  at  the  same  time  they  are  abnormally 
sexually  excited,  and  the  result  is  sometimes  very  depressing  and  dis- 
couraging. In  many  instances  great  harm  results  to  those  patients  by 
their  persistence  in  masturbation,  futile  attempts  at  coitus,  and  dal- 
liance with  women.  The  result  in  many  cases  is  physical  and  mental 
exhaustion. 

As  catarrhal  prostatitis  becomes  chronic  in  some  cases  the  morbid 
process  creeps  up  the  ejaculatory  ducts  and  involves  the  mucous  mem- 
brane and  that  of  the  ampullae  and  of  the  seminal  vesicles.  The 
direct  result  of  this  extension  is  a  more  or  less  severe  catarrhal  condi- 
tion of  these  parts.  But  the  most  striking  effect  produced  is  a  condi- 
tion of  flabbiness  of  the  outlet  ducts  of  the  ampullae  and  of  the  seminal 
vesicles  and  the  development  of  more   or  less   patulousness  in  the  not 


296  AFFECTIONS  OF  THE  PROSTATE. 

verv  strong  muscular  fibres  of  the  ejaculatory  ducts.  The  process 
which  really  takes  place  in  all  these  parts  which  normally  safeguard  the 
retention  of  the  semen  and  prevent  its  escape,  is  one  of  weakness  and 
of  incompetence,  which  allows  the  secretion  to  escape  under  various 
mechanical  conditions  (abdominal  pressure,  defecation,  particularly  with 
firm  fecal  bolus,  and  urination).  When,  therefore,  chronic  prostatitis 
is  present  with  this,  as  we  may  term  it,  seminal  incontinence,  the 
abnormal  ejaculate  is  composed  of  prostatic  mucus  and  some  of  the 
secretion  of  the  ampulla?  and  seminal  vesicles.  Asa  rule,  the  amount 
of  this  fluid  lost  at  any  time  by  these  patients  is  very  small.  The  loss 
of  this  secretion  per  se  is  not  the  cause  of  the  deterioration  of  the 
health  of  the  patient,  as  is  so  generally  believed.  The  real  morbid 
factors  are  the  local  lesions  and  the  resulting  mental  unbalance  and 
general  depression  of  the  economy. 

Catarrhal  Prostatitis  in  Older  Subjects. 

There  is  no  uniformity  in  the  clinical  history  of  the  cases  of  chronic 
prostatitis  in  patients  beyond  the  thirtieth  year.  In  some  cases  the 
symptoms  are  few  and  not  well  marked ;  in  others  they  are  more  pro- 
nounced, while  in  a  few  so  striking  is  the  symptom-complex  that 
prostatic  inflammation  at  once  suggests  itself  to  the  mind  of  the  surgeon. 
In  these  older  patients  we  do  not  have  to  listen  to  so  much  persistence 
in  the  recital  of  their  troubles  concerning  sexual  discharges  and  the 
multifarious  symptoms  of  sexual  neurasthenia  as  we  do  in  younger 
subjects.  Older  patients  may  become  ansemic,  and  even  more  or  less 
neurasthenic,  but  they  rarely  reach  the  deplorable  condition  so  often 
seen  in  voting  subjects.  The  older  patients,  as  a  rule,  have  started  in 
sexual  life  with  their  organs  in  a  healthy  condition,  and  disease  has  set 
in  later.  In  the  younger  subjects  the  integrity  of  their  sexual  organs 
was  much  impaired  and  damaged  before  and  at  puberty. 

Examination  of  the  prostate  by  means  of  the  finger  in  the  rectum 
of  these  older  patients  gives  somewhat  different  results  from  those  found 
in  voung  subjects.  The  whole  prostate  may  be  symmetrically  enlarged 
to  as  much  as  double  its  normal  size  ;  only  one-half  of  it  may  be  more  or 
less  enlarged,  or  we  may  only  find  one  or  more  well-defined  large  or 
small  lumps,  which,  in  exceptional  cases,  may  have  a  soft  structure. 
But  in  these  cases,  as  a  rule,  there  is  evidence  of  firm  structure,  even 
approaching  true  hardness,  and  the  finger-tip  gives  the  surgeon  the 
impression  that  marked  cell-proliferation  must  have  occurred  in  the 
organ.  This  clinical  fact  is  clearly  explained  by  the  results  of  histo- 
logical studies,  which  have  shown  that  with  the  chronicitv  of  the  in- 
flammatory  process  new  connective  tissue  has  been  developed  around 
the  tubules  to  such  an  extent  as  to  produce  a  semi-sclerotic  condition 


CATARRHAL   PROSTATITIS  IN  OLDER  SUBJECTS.  297 

of  the  gland.  For  a  long  time  this  new  cell-growth  causes  the  decided 
increase  in  the  size  of  the  gland  which  has  been  mentioned,  but  later  on 
a  cirrhotic  condition  sets  in,  by  which  the  size  of  the  gland  is  materially 
decreased,  even  to  the  point  of  atrophy. 

It  is  sometimes  observed  that  when  one  lobe  of  the  prostate  is  attacked 
there  is  pain  in  the  corresponding  side  of  the  rectum.  This  condition 
is  also  found  in  some  cases  of  unilateral  seminal  vesiculitis.  In  still 
other  cases  we  find  an  enlarged,  somewhat  eburnated  organ,  which  is 
the  seat  of  firm,  half-pea-sized  nodulations. 

With  the  continuance  of  the  chronic  catarrhal  process  the  lumen 
of  the  tubes  in  many  cases  becomes  more  or  less  plugged  up  by  phos- 
phatic  concretions,  by  desiccated  masses  of  old,  cast-oif  epithelial  cells, 
and  by  amyloid  bodies.  Some  of  these  abnormal  products  may  be 
sometimes  observed  in  younger  patients. 

Catarrhal  prostatitis  in  older  subjects  not  infrequently  gives  rise  to 
very  poorly  marked  symptoms.  Some  patients  complain  of  uneasiness, 
as  they  term  it,  at  the  neck  of  the  bladder,  and  others  speak  of  more 
or  less  deep  pelvic  pain,  which  they  think  is  in  some  manner  connected 
with  the  rectum.  In  some  cases  the  pain  is  felt  on  standing  up,  in 
others  after  muscular  exertion,  bicycle  exercise,  and  horseback-riding, 
while  in  still  others  it  is  felt  when  in  certain  positions  on  sitting  down, 
particularly  on  the  edge  of  a  chair.  In  some  cases  the  uneasiness  is 
also  felt  in  the  perineum  and  anus,  and  in  other  cases  on  one  side  of  the 
body  corresponding  to  the  side  of  the  prostate  involved.  In  some  cases 
pain  in  one  hip-joint  is  complained  of.  In  many  of  these  cases  there  is 
frequency  of  urination,  and  in  some  there  is  pain  in  the  glans  penis  at 
the  end  of  the  act.  Most  patients  thus  affected  have  some  form  of 
sexual  weakness,  which  is  either  mild  or  pronounced,  and  some  have 
abnormal  mucoid  discharges. 

The  uneasiness  and  pain  in  the  prostate  may  be  more  or  less  contin- 
uous, or  mildly  paroxysmal,  or  it  may  be  rendered  worse  when  the 
bladder  is  much  distended  and  when  constipation  or  diarrhoea  is  present, 
in  which  instances  there  may  be  decided  tenesmus. 

Some  of  these  patients  speak  of  a  vague  feeling  of  numbness  deep 
in  the  pelvis  and  in  the  prostate,  and  this  feeling  may  also  exist  in  the 
perineum.  In  these  cases  there  may  not  be  much  disturbance  of  the 
health,  though  some  patients  become  ansemic  and  worried. 

In  marked  contrast  with  the  foregoing  mild  order  of  cases  are  those 
in  which  the  symptoms  are  numerous,  severe,  and  complex.  In  these 
cases  there  is  more  or  less  ill  health,  and  in  some  neurasthenia.  Such 
patients  first  complain  of  vague  and  sometimes  fugitive  pains  in  the 
back,  loins,  and  pelvis.  Inquiry  then  will  usually  bring  out  the  state- 
ment that  there  is  increased  frequency  of  urination,  and  perhaps  pain  in 


298  AFFECTIONS  OF  THE  PROSTATE. 

the  prostate  and  the  glans  at  the  end  of  the  act,  and  that  their  sexual 
capacity  is  rather  weak.  Sometimes  it  will  be  found  that  one  lobe  of 
the  prostate  has  been  involved,  and  that  the  pain  in  the  glans  penis  is 
referred  by  the  patient  to  the  corresponding  side  of  the  prostate  gland. 
There  may  be  present  either  sexual  apathy  or  erethism.  These  patients 
sometimes  notice  the  escape  of  morbid  mucus,  which  may  be  thin  and 
milky,  or  clear  and  very  viscid  (like  liquid  glue),  or  it  may  look  like 
condensed  milk  or  very  thick  glue.  When  in  these  conditions  the 
ampullations  and  the  seminal  vesicles  are  also  involved,  some  of  their 
secretion  may  escape  and  become  mixed  with  the  prostatic  mucus,  in 
which  event  the  secretion  is  usually  of  a  yellowish-brown  color.  It 
will  generally  be  found,  in  these  older  patients,  that  when  the  secretion 
comes  from  the  prostate  it  is  white  or  slightly  turbid,  like  liquid  glue, 
or  grumous,  but  that  when  it  comes  from  the  ampullations  it  is  of  a 
yellowish-brown  or,  exceptionally,  of  a  dark-brown  tint.  The  diagnos- 
tic indications  which  are  observed  by  inspection  of  the  color  of  the 
morbid  mucus  from  the  deep  seminal  parts  can  readily  be  verified  by 
microscopic  examination. 

The  urine  of  these  patients  is  usually  of  rather  low  specific  gravity 
(1008  to  1013),  of  pale  color,  of  feeble  acidity,  or  perhaps  it  may  be 
quite  constantly  alkaline.  It  is,  as  a  rule,  rather  opaque  and  sometimes 
of  decidedly  milky  hue,  and  upon  its  surface  very  frequently  an  irides- 
cent pellicle  forms.  The  phosphatic  salts,  being  in  great  excess,  some- 
times appear  like  a  sheen  of  little  whitish  glistening  particles.  On 
standing  in  the  cylinder  or  urine-glass  the  sediment  first  collects 
throughout  the  specimen  in  little  cloudy  tufts,  somewhat  resembling 
water  which  is  slowly  freezing.  Then,  in  a  short  time,  the  sediment 
sinks  to  the  bottom  of  the  glass  and  forms  a  tolerably  thick  mass,  which 
has  a  flocculent,  grayish-Avhite  appearance,  very  different  from  that 
presented  by  pus. 

In  some  of  these  cases  of  chronic  prostatitis  in  older  subjects  (and 
it  is  sometimes  seen  in  younger  patients)  a  peculiar  form  of  emission 
or  ejaculate  is  observed  which  needs  description.  Such  patients  more 
or  less  frequently  see,  after  urination  or  defecation  or  hard  work,  a 
thick  ropy,  whitish  mass  escape  from  the  urethra  which  looks  like 
plaster  of  Paris  mixed  with  water.  In  some  cases  the  escape  of  this 
stuff  is  unattended  with  any  unpleasant  symptom,  but  in  others  there 
is  a  sensation  of  sickness  at  the  stomach  and  great  weakness  during  and 
for  a  time  after  its  passage.  In  some  cases  there  is  a  scalding  sensation 
in  the  whole  course  of  the  urethra,  beginning  at  the  prostate,  and  such 
may  be  the  patient's  suffering  that  he  becomes  pallid,  is  thrown  into 
a  cold  sweat,  and  he  may  be  on  the  point  of  fainting.  This  discharge 
may  occur  at  short  or  quite  long  intervals,  and  the  fear  of  its  occur- 


CATARRHAL  PROSTATITIS  IN  OLDER  SUBJECTS.  299 

rence  creates  in  the  minds  of  some  patients  great  apprehension  and 
fear. 

Microscopic  examination  of  these  abnormal  discharges  shows  that 
they  are  composed  of  mucus  and  granular  phosphates,  together  with 
(in  some  instances)  triple  phosphates  and  crystalline  phosphate  of  lime. 
There  may  also  be  other  components,  such  as  pus-cells,  prostatic  epithe- 
lium, and  some  spermatozoa.  Many  of  these  patients  think  that  they  are 
suffering  from  a  particularly  severe  form  of  spermatorrhoea,  and  they 
may  become  much  depressed  in  mind  and  even  mildly  neurasthenic. 

In  some  cases  of  chronic  prostatitis  in  older  subjects  there  is  at  one 
time  hyperesthesia  of  the  prostatic  urethra,  in  which  event  there  may 
be  much  sexual  erethism,  some  frequency  of  urination,  and  more  or 
less  pain  in  the  whole  act.  Ejaculation  may  be  somewhat  premature, 
but  it  is  usually  attended  with  unpleasant,  even  painful,  sensations, 
which  may  soon  cease  or  which  may  last  for  hours  or  for  a  day  or  two. 
In  some  of  these  cases  of  erethism  the  penis  is  often  in  a  semi-erect 
condition,  and  prostatic  mucus  flows  from  the  urethra  at  times. 

The  course  of  this  hypersensitiveness  of  the  prostate  and  prostatic 
urethra,  when  uninfluenced  by  treatment,  is  much  prolonged,  and  it 
may  be  uneventful  or  be  attended  by  marked  exacerbations.  As  time 
elapses  the  erethism  gradually  ceases  and  in  some  cases  it  is  followed 
by  very  decided  anaesthesia  in  the  parts,  which  may  extend  throughout 
the  course  of  the  urethra,  and  in  a  mild  form  involve  the  bladder. 
There  may  also  be  partial  insensitiveness  of  the  testes,  scrotum, 
perineum,  and  upper  portions  of  the  thighs.  In  some  rather  rare  cases 
of  prostatitis  with  involvement  of  the  ampullae  and  of  the  seminal 
vesicles  I  have  seen  this  queer  association  of  these  numb  sensations. 
In  this  condition  there  may  be  interference  with  the  function  of  urina- 
tion and  with  coitus.  Such  patients  state  that  sometimes  they  are  not 
aware  of  the  fact  that  the  bladder  is  full,  and  when  they  attempt  its 
evacuation,  though  the  stream  may  be  full  in  size,  it  is  feeble  and  more 
or  less  halting.  Then,  again,  erections  may  be  normal,  but  ejaculation 
is  feeble,  and  the  sexual  act  may  suddenly  collapse. 

By  massage  of  the  prostate  thus  affected  we  cause  the  escape  of 
several  forms  of  mucus  which  present  somewhat  different  features  from 
one  another.  This  expressed  secretion  may  consist  of  mucus  or  mucus 
and  glandular  phosphates,  perhaps  combined  with  triple  phosphates  and 
phosphate  of  lime,  or  it  may  contain  degenerated  prostatic  epithelium, 
pus,  spermatozoa,  phosphatic  concretions,  amyloid  bodies,  and  cylindrical 
casts  of  the  prostatic  tube-glands. 

In  these  older  cases  it  is  very  common  to  see  (as  we  sometimes  do 
in  the  secretion  of  younger  subjects)  the  granular  phosphates  arranged 
in  the  shape  of  regular  cylinders,  which  are  straight  or  more  or  less 


300  AFFECTIONS  OF  THE  PROSTATE. 

curved.  These  cylinders  are  formed  in  the  tubules  by  the  functional 
overactivity  of  the  prostatic  epithelial  cells.  Phosphate  of  lime  is 
formed  in  excess  at  the  same  time  that  a  thick,  gluey  mucus  is  prolifer- 
ated. These  two  component  parts,  remaining  for  a  time  in  the  tubules, 
become  amalgamated,  and  the  mucophosphatic  cylinders  are  the  result. 
These  granular  phosphates  also  give  rise  in  the  prostate  to  certain  little 
oval  or  round  bodies,  to  which  the  term  prostatic  concretions  should, 
I  think,  be  applied.  They  are  small  masses,  composed  of  the  same 
structures  as  the  cylinders — namely,  mucus  and  granular  phosphates. 
They  are  variously  colored ;  some  are  yellow  (and  may  be  mistaken  for 
urates,  but  chemical  analysis  will  prove  their  true  nature),  or  they  may 
be  moderately  red  or  of  a  deep  purple  tint.  These  little  bodies  remain 
in  an  indolent  manner  in  the  tubules  (and  undoubtedly  cause  pain  and 
uneasiness),  and  they  may  excite  more  or  less  hemorrhage,  in  which 
event  they  become  colored  to  a  greater  or  less  extent.  These  phosphatic 
concretions  may  become  the  nuclei  of  calculi.  In  some  specimens  of 
urine  and  of  expressed  prostatic  secretion  we  find  very  firm  threads, 
which  are  of  a  yellowish,  a  brown,  or  purple  color,  which,  on  examina- 
tion are  found  to  consist  of  granular  phosphates,  mucus,  and  altered 
blood-cells.  These  threads  are  undoubtedly  the  initial  forms  of  the 
little  colored  phosphatic  concretions. 

In  some  exceptional  cases,  particularly  of  old  men,  we  find  well- 
marked  hyaline  cylinders. 

These  hyaline  cylinders,  which  look  like  large  hyaline  renal  casts, 
are  undoubtedly  due  to  the  inflammatory  exudation  which  takes  place 
in  the  depth  of  the  gland-tubules.  They  are  sometimes  quite  long, 
wavy,  of  irregular  contour,  and  in  some  cases  somewhat  bulbous  on 
one  end.  They  are  not  of  constant  occurrence,  and  are  usually  found 
in  cases  in  which  the  painful  symptoms  are  well  marked. 

Amyloid  bodies  are  not,  as  stated  in  the  books,  of  frequent  occur- 
rence. They  are  seldom  seen  in  the  prostatic  secretion  of  younger  sub- 
jects, and  are  rather  exceptionally  found  in  that  of  older  patients. 

Small  prostatic  concretions  resembling  mustard-seeds  may  be  found 
in  the  ducts  of  many  tube-glands,  and  they  may  cause  any  of  the  fore- 
going painful  symptoms.  These  little  round,  brownish,  shot-like  masses 
are  largely  composed  of  mucus  and  lime  salts. 

There  can  be  no  doubt  that  these  various  concretions  just  described 
act  as  foreign  bodies  which,  by  plugging  up,  destroy  the  function  of  the 
tubules,  and  by  their  presence  give  rise  to  the  uneasy  sensations  and 
pains  complained  of  by  these  patients  under  varying  conditions  (sitting 
down,  horseback  and  bicycle  exercise,  golf,  urination,  defecation,  and 
copulation). 

Chronic  prostatitis  in   older  subjects,  as  in  younger  ones,  may  be 


PR  OSTA  TORRHCEA .  30 1 

complicated  with  chronic  bulbous  or  posterior  urethritis,  and  it  is  not 
infrequently  coexistent  with  chronic  inflammation  of  the  ampulla?  and 
of  the  seminal  vesicles.  When  these  sacs  at  the  base  of  the  bladder 
are  involved  there  may  be  the  same  seminal  incontinence  which  is  ob- 
served in  young  men. 

Prostatorrhcea. — In  some  rare  cases  of  chronic  prostatitis  the  dis- 
charge is  so  copious  that  the  term  prostatorrhoea  has  been  applied  to 
them.  In  these  cases,  when  they  are  well  marked,  there  seems  to  be  a 
continual  production  of  mucus  by  the  prostatic  tubular  glands  ;  there- 
fore, the  most  constant  symptom  is  the  escape  from  the  meatus  of  a  clear 
mucous  fluid  or  of  a  mucus  mixed  with  pus  and  perhaps  a  little 
blood.  This  mucous  fluid  may  be  scant  in  quantity,  only  a  few  drops 
appearing  at  the  meatus  in  a  day.  It  may  also  be  more  copious,  and 
keep  the  end  of  the  penis  in  a  moist  condition  continuously,  and  in  very 
pronounced  cases  the  escape  is  so  excessive  that  patients  complain  of  a 
constant  and  annoying  "  dripping,"  which  may  wet  and  stain  a  large 
part  of  their  shirt-flap  or  of  the  handkerchief  which  they  instinctively 
make  use  of  under  these  circumstances.  Riders  of  some  forms  of 
bicycles  notice  that  a  clear  viscid  secretion  escapes  from  the  meatus, 
particularly  after  long  and  rough  riding.  Seeing  that  in  many  of  these 
cases  there  are  no  symptoms  which  point  to  prostatic  or  vesical  disturb- 
ance, it  seems  probable  that  the  fluid  comes  from  hypersemic  mucous 
follicles  and  Cowper's  glands.  But  many  riders  who  suffer  from 
catarrhal  prostatitis  state  that  they  have  a  more  or  less  copious,  clear 
or  cloudy  mucous  discharge.  The  escape  of  this  discharge  in  large 
quantities  occurs  frequently  during  the  act  of  defecation,  particularly 
when  the  fecal  bolus  is  hard  and  firm.  In  some  cases  the  escape  of  the 
mucus  causes  a  peculiar  tickling  feeling  in  the  prostate  and  urethra, 
while  in  others  it  produces  pleasurable  voluptuous  and  lascivious  sensa- 
tions. Some  patients  claim  that  they  can  feel  the  escape  of  the  fluid 
from  the  prostate  into  the  urethra.  In  rather  rare  cases  the  escape  of 
mucus,  particularly  after  defecation,  is  attended  with  a  sickening  sensa- 
tion of  great  faintness,  which  may  last  for  several  minutes.  Many  of 
these  cases  have  been  treated  for  spermatorrhoea. 

Although  we  have  no  pathological  knowledge  on  the  subject,  it  seems 
fair  to  assume  that  in  prostatorrhoea  there  is  such  an  atonic  condition 
of  the  compressor  urethra?  muscle  that  it  cannot  prevent  the  escape  of 
the  fluid  into  the  anterior  urethra.  The  next  most  constant  symptom 
is  increased  frequency  in  urination,  which  may  be  very  excessive  or 
only  about  twice  as  often  as  the  normal  desire.  There  may  be  decided 
uneasiness  at  the  end  of  the  act,  and  there  may  be  a  slight  pain  or 
decided  scalding  sensation,  which  passes  from  the  prostate  to  the  end 
of  the  penis.     In  many  cases  the  stream  is  small  and  weak — a  con- 


302  AFFECTIONS   OF  THE  PROSTATE. 

dition  which  seems  to  point  to  an  atonic  state  of  the  detrusors.  A 
sense  of  dulness  and  weight  is  often  felt  in  the  prostate  and  in  the 
rectum,  and  pain  and  uneasy  sensations  are  experienced  in  the  perineum, 
thighs,  and  lumbo-sacral  regions. 

Some  patients  suffer  from  chronic  prostatorrhoea  without  becoming 
much  disturbed  in  mind  by  it.  But  there  are  others  to  whom  this 
affection  is  little  less  than  a  calamity.  They  become  exceedingly 
nervous  about  their  trouble,  even  to  the  extent  of  being  melancholy. 
They  lose  flesh,  strength,  and  appetite ;  they  become  irritable  and  in- 
capable of  mental  and  physical  exertion.  In  fact,  in  some  cases  the 
whole  morale  of  the  man  seems  lost. 

In  many  cases  of  prostatorrhoea  there  is  more  or  less  disturbance  in 
the  sexual  function.  In  some  subjects  it  is  morbidly  exaggerated ;  in 
others  there  is  much  desire,  much  erethism,  many  erections,  but  very 
little  is  accomplished,  owing  to  the  precipitate  ejaculations.  In  still 
other  subjects  there  is  little  if  any  desire,  even  as  a  result  of  much 
excitement,  and  the  penis  and  scrotum  seem  shrunken,  cold,  and 
lethargic. 

Rectal  examination  of  cases  of  prostatorrhcea  reveals  an  enlarged 
organ,  usually  jutting  more  or  less  backward  on  the  gut,  and  being 
decidedly  broader  than  normal.  Very  often  only  one  lobe  or  a  portion 
of  one  may  be  involved.  Sometimes  it  feels  soft,  and  again  it  may 
seem  decidedly  indurated.  There  is  commonly  more  or  less  tender- 
ness, even  severe  pain,  on  pressure  by  the  finger-tips.  Urethral  ex- 
amination, even  with  a  small  and  not  stiff  instrument,  often  causes  a 
great  outcry  from  pain  when  the  tip  passes  through  the  prostatic  urethra. 

Diagnosis. — When  the  foregoing  descriptions  of  clinical  cases  are 
borne  in  mind  the  suspicion  of  chronic  prostatitis  will  force  itself  upon 
the  surgeon's  mind.  Then  rectal  palpation  will  reveal  the  extent 
and  severity  of  the  local  condition.  At  the  same  time  the  condition 
of  the  urine  must  be  examined,  and  it,  with  any  expressed  mucus, 
must  be  carefully  studied  by  means  of  the  microscope.  If  these  re- 
quirements are  fulfilled,  a  very  satisfactory  estimate  of  the  case  can 
always  be  made. 

Chronic  prostatitis  may  be  caused  by  tuberculosis,  and  by  the  exer- 
cise of  care  and  skill  a  correct  diagnosis  can  soon  be  positively  made. 
The  examination  of  the  urine  in  these  cases  for  the  bacillus  tuberculosis 
will  in  many  true  cases  be  unattended  with  the  detection  of  the  micro- 
organism. It  is  absolutely  necessary  in  these  cases  to  examine  prefera- 
bly the  expressed  or  the  escaped  prostatic  secretion  after  proper  staining. 
Great  care  should  be  taken  that  the  penis,  and  particularly  the  glans,  be 
rendered  absolutely  sterile,  since  upon  these  parts  the  smegma-bacillus 
lives  and  hibernates,  and  the  detection  of  this  inert  microbe  might  lead 


TREATMENT  OF  CHRONIC  PROSTATITIS.  303 

the  unwary  examiner  to  mistake  it  for  that  deadly  bacillus  which  causes 
tuberculosis. 

But,  in  addition  to  the  condition  of  the  prostate,  the  surgeon  must 
make  himself  familiar  with  that  of  the  urethra,  chiefly  its  bulbous  and 
prostatic  portions,  and  also  of  the  state  of  the  seminal  vesicles  and  of 
the  ampullations.  In  forming  an  estimate  of  a  case  it  is  well  to  bear  in 
mind  that  in  young  individuals  a  more  or  less  recent  gonorrhoea  may 
have  existed,  and  that  it  is  very  common  to  find  the  damage  quite 
sharply  limited  to  the  deep  urethra  and  prostate,  and  perhaps  largely  to 
that  gland.  It  is  exceptional  to  find  seminal  vesicular  involvement  in 
young  subjects.  In  older  individuals  the  prostate  and  the  seminal  vesi- 
cles and  ampullations  may  be  the  seat  of  chronic  inflammation,  and  this 
complicated  condition  can  be  clearly  made  out  by  rectal  exploration, 
and  by  microscopic  study  of  the  expressed  secretions  or  of  the  urinary 
sediment. 

Prognosis. — In  very  many  uncomplicated  cases  of  catarrhal  pros- 
tatitis most  satisfactory  results  follow  the  adoption  of  proper  treatment. 
In  every  case,  if  the  patient  persists  in  sexual  or  alcoholic  excesses  or 
in  any  way  transgresses  against  the  rules  of  sexual  hygiene,  his  ultimate 
cure  will  be  greatly  retarded. 

In  young  men  suffering  from  the  effects  of  masturbation  and  chronic 
posterior  urethritis  the  prognosis  is,  as  a  rule,  good,  provided  the  patient 
is  not  very  anaemic  or  neurasthenic.  In  those  cases  in  which  the  morale 
of  the  patient  is  much  below  par  the  progress  toward  cure  is  slow  and 
often  unsatisfactory  and  halting.  The  occurrence  of  cystitis  by  exten- 
sion, particularly  in  chronic  masturbators,  is  of  serious  import,  for  such 
cases  are  very  refractory  to  the  most  careful  forms  of  treatment. 

In  very  many  older  men  an  excellent  prognosis  may  be  given  if 
they  can  control  their  sexual  tendencies  by  moderation  and  will  not 
overindulge  in  alcohol.  The  coexistence  of  chronic  posterior  urethritis, 
of  seminal  vesiculitis,  or  of  chronic  inflammation  of  the  ampullae  is  a 
rather  serious  drawback  which  may  tax  the  skill  and  patience  of  the 
surgeon.  Very  many  of  these  cases,  however,  are  much  benefited, 
and  even  unpromising  ones  can  be  cured. 

Treatment. — The  first  essentials  in  the  treatment  of  chronic  pros- 
tatitis are  a  regular,  quiet  life,  abstinence  from  alcoholics,  and  the 
avoidance  of  all  kinds  of  sexual  excess  or  excitement.  A  bland  nutri- 
tious diet  should  be  taken,  and  spices,  coffee,  cocoa,  highly  seasoned 
dishes,  and  asparagus  should  be  avoided.  The  rectum  should  be  thor- 
oughly emptied  every  day  at  least  once,  and  if  the  natural  evacuation 
does  not  occur  a  mild  aperient  must  be  taken.  These  patients  must 
avoid  taking  cold,  and  they  should  not  take  part  in  violent  sports,  nor 
should  they  indulge  in  bicycle  exercise. 


304  AFFECTIONS   OF  THE  PROSTATE. 

Moderate  and  rather  infrequent  sexual  intercourse  may  be  practised, 
provided  no  ill  effects  are  found  to  follow  it. 

When  chronic  bulbous  or  posterior  urethritis  is  present  active  treat- 
ment must  be  instituted  for  the  relief  of  these  conditions,  which  materi- 
ally aggravate  the  case  and  render  it  more  rebellious.  In  like  manner 
strictures  of  the  urethra  should  receive  proper  attention  and  treatment. 
Instillations  of  nitrate  of  silver,  irrigations  with  watery  solutions  of 
the  same  salt  (1  to  500,  1000,  to  2000),  of  permanganate  of  potassium 
(1  to  4000  to  10,000),  or  of  sulphate  of  zinc  and  alum  (1  each  to  500 
to  1000),  may  be  given  every  few  days. 

In  many  cases  the  careful  introduction  of  a  steel  sound  cooled  in 
ice-water,  every  four  to  seven  days,  is  most  grateful  and  beneficial. 
The  psychrophor  may  be  used  instead  of  the  sound  if  the  surgeon  so 
desires. 

Direct  treatment  to  the  prostate  by  the  surgeon  may  be  made  by 
means  of  the  finger-tip  in  the  patient's  rectum.  Preparatory  to  begin- 
ning the  treatment  of  massage  of  the  prostate  the  surgeon  should  ac- 
quaint himself  with  the  size  of  the  organ  and  ascertain  what  part  is 
affected,  or  whether  the  totality  of  the  gland  is  involved.  Then  the 
relative  softness,  bogginess,  and  hardness  should  be  learned.  When  the 
conditions  of  the  organ  are  ascertained  full  details  thereof  should  be 
noted  down  for  future  reference  and  comparison.  The  main  object  is  to 
reduce  the  size  of  the  swollen  organ,  and  by  massage  we  press  out  patho- 
logical products  (vide  supra),  stimulate  the  tissues,  and  cause  the  absorp- 
tion of  more  or  less  of  the  inflammatory  exudation,  by  means,  probably, 
of  the  increased  circulation  in  the  vessels  and  lymphatics.  In  addition 
to  these  changes,  we  undoubtedly  give  tone  and  resiliency  to  the  flabby 
bloodvessels  and  also  stimulation  to  the  relaxed  muscular  fibres.  A 
certain  healthy  stimulus  seems  to  be  communicated  to  the  nerves  of  the 
prostate  by  judiciously  administered  massage.  The  technique  of  the 
operation  is  very  simple.  The  patient  stands  with  his  feet  slightly 
separated  and  bends  the  body  forward  at  a  right-angle.  Then  the  sur- 
geon, having  liberally  greased  his  forefinger  with  vaselin,  gently  inserts  it 
until  he  reaches  the  prostate.  Then,  by  means  of  extended  lateral  and 
up-and-down  gentle  but  firm  pressure,  he  thoroughly  kneads  the  organ. 
Patients  act  and  feel  very  differently  while  this  operation  is  taking  place. 
Some  cry  out  with  pain,  particularly  at  the  first  seance,  others  suffer  a 
little  and  make  no  complaint,  while  others  are  entirely  passive  and  per- 
haps say  that  the  sensation  is  a  little  unpleasant.  In  some  patients 
partial  or  full  erections  are  produced,  and  in  almost  all  of  them  there  is 
inability  to  urinate  for  several  minutes  after  the  operation.  The  secre- 
tions which  are  expressed  have  already  been  described. 

In  most  cases  prostatic  massage  produces  much  benefit  and  comfort, 


TREATMENT  OF  CHRONIC  PROSTATITIS.  305 

but  in  some  it  is  necessary  to  proceed  very  guardedly,  lest  irritation  be 
set  up.  No  absolute  rule  can  be  laid  down  as  to  the  frequency  of  repe- 
tition of  this  treatment.  In  general,  one  massage  in  five  or  seven, 
or  even  ten  days,  will  be  found  sufficient  to  produce  good  results. 
When  there  is  concomitant  chronic  urethritis  of  the  bulb,  posterior 
urethritis,  or  involvement  of  the  verumontanum,  the  patient  may  be 
more  or  less  sensitive  to  this  procedure,  and  it  behooves  the  surgeon  to 
proceed  slowly  and  carefully.  The  indications  for  the  continuance  and 
the  frequency  of  the  massage  are  the  comfort  and  benefit  the  patient 
says  he  experiences,  and  also  the  moral  eifect,  which  in  many  cases 
transforms  a  gloomy  and  foreboding  patient  into  a  cheerful  and  hopeful 
one.  As  a  rule,  when  no  ill  effects  are  produced,  as  attested  by  the 
feeling  of  general  and  local  comfort  experienced  by  the  patient,  when 
there  is  no  abnormal  desire  to  urinate,  and  when  pus  in  unusual  quan- 
tity does  not  appear  in  the  urine,  the  surgeon  may  be  certain  that  he  is 
on  the  right  track,  and  can  continue.  He  can  also  gain  much  informa- 
tion by  ascertaining  from  his  records  how  much  involution  in  the  pros- 
tate he  has  produced,  and  by  repeated  microscopical  examinations  in 
auspicious  cases  he  can  convince  himself  that  the  pus,  effete  epithelial 
cells,  granular  phosphates,  perhaps  tube-casts,  prostatic  concretions, 
and  amyloid  bodies  are  growing  less  numerous  as  the  patient  improves 
in  every  particular.  During  the  massage  treatment  rectal  irrigations 
with  very  warm  water,  administered  by  means  of  Kemp's  instrument, 
are  often  of  signal  benefit  in  causing  the  involution  of  the  swollen  organ 
and  the  absorption  of  diseased  products.  In  some  cases,  also,  cold 
water  thus  administered  seems  to  be  very  beneficial. 

In  order  to  obtain  the  beneficial  effects  of  heat  in  the  rectum  it  may 
be  necessary  to  use  water  of  the  temperature  of  100°  to  120°  F.  The 
increase  in  heat  can  be  accomplished  gradually  until  the  higher  temper- 
ature of  130°  F.  is  reached.  When  hot  water  is  thus  used,  many 
patients  from  the  very  first  experience  great  relief  and  gladly  consent 
to  the  elevation  of  the  temperature  of  the  irrigations.  It  is  probable 
that  these  hot  rectal  applications  prove  beneficial  by  their  stimulant 
action  upon  the  nerves,  the  bloodvessels,  and  lymphatics. 

The  use  of  cold  water  by  rectal  irrigations  should  be  carefully 
watched,  and  it  should  be  discontinued  at  once  if  discomfort  to  the 
patient  is  produced.  The  temperature  of  cold  irrigations  should  range 
from  50°  F.  to  that  of  ice-water. 

I  know  of  no  morbid  condition  in  which  such  reliable  data  can  be 
obtained  by  physical  and  microscopical  examinations  of  the  patient  and 
of  his  urine  as  are  presented  by  cases  of  chronic  prostatitis. 

Many  cases  of  chronic  prostatitis  are  much  benefited  by  tonic  mix- 
tures which  contain  goodly  doses  of  nitro-nmriatic  acid  combined  with 

20 


306  AFFECTIONS   OF  THE  PROSTATE. 

strychnine  and  quinine.  The  neurasthenia  and  weakness  which  very 
often  occur  in  the  course  of  chronic  prostatitis  should  be  carefully 
treated.  Such  patients  should  receive  kindly  encouragement,  and  their 
general  well-being  should  be  sedulously  cared  for. 

In  addition  to  systematic  local  treatment,  much  benefit  may  follow 
the  internal  administration  of  full  doses  of  fluid  extract  of  ergot  and 
strychnine.  The  muriate  tincture  of  iron  combined  with  strychnine  is 
sometimes  very  efficient,  particularly  in  debilitated  subjects. 

It  is  also  well  to  mention  mercurial,  ichthyol,  and  iodide  of  potas- 
sium suppositories,  which  should  be  introduced  into  the  rectum  every 
night.  The  inert  basis  of  these  suppositories  is  a  mixture  of  cocoa-but- 
ter and  white  wax.  In  each  suppository  may  be  incorporated  twenty 
grains  of  strong  mercurial  ointment,  fifteen  to  twenty  drops  of  ichthyol, 
and  thirty  grains  of  the  iodide  of  potassium. 

LESIONS  OF  THE  EJACULATORY  DUCTS. 

A  variety  of  morbid  conditions  may  occur  in  and  around  the  ejacu- 
latory  ducts.  The  plugging  up  of  these  minute  canals  by  sympexia  is 
of  rather  rare  occurrence. 

It  is  very  probable  that  the  great  distention  of  one  ejaculatory  duct 
blocks  the  other  one  up  very  effectually,  as  these  canals  lie  so  close 
together  in  the  prostate. 

Cases  have  -been  reported  in  which,  on  post-mortem  examination, 
the  ejaculatory  ducts  have  been  found  to  be  plugged  by  concretions  as 
large  as  a  pea  or  a  cherry,  which  were  composed  of  carbonate  and  phos- 
phate of  lime,  and  mucus  and  spermatozoa.  Chronic  gonorrhoea  has 
been  found  to  produce  a  stenosing  condition  of  the  ejaculatory  ducts, 
chiefly  by  its  round-cell  infiltration  of  the  submucous  connective  tissue 
of  the  verumontannra,  which  it  attacks  more  severely  than  other  por- 
tions of  the  posterior  urethra.  Round-cell  infiltration  around  the  ducts 
producing  stenosis  has  been  found  in  the  dead  subject. 

Dense  fibrous  bands  upon  and  behind  the  verumontanum  have  been 
seen  to  so  compress  or  distort  the  ejaculatory  ducts  that  either  stenosis 
has  been  produced,  or  a  deviation  in  the  course  of  the  ducts  or  of  their 
orifices  has  resulted.  In  the  former  event  the  semen  was  dammed 
backward;  in  the  latter  it  was  in  coitus  thrown  backward  into  the 
bladder. 

Arch-like  bands  of  fibrous  tissue  have  been  found  seated  saddle-like 
across  the  summit  of  the  verumontanum,  and  as  a  consequence  one  or 
both  ducts  were  obliterated.  Gonorrhoea  may  cause  abscess-formation 
in  some  or  many  of  the  prostatic  tubules,  which  may  result  in  such 
scar-tissue  development  that  the  ejaculatory  ducts  are  destroyed. 

In  some  cases  of  chronic  gonorrhoea  the  involvement  of  the  tubules 


HYPERTROPHY.  307 

of  the  prostate  has  ended  in  cystic  degeneration,  which  was  produced 
by  sclerosis  of  the  tissues  and  obliteration  of  the  ducts. 

Cases  are  on  record  in  which  traumatism  of  the  prostate  and  veru- 
montanum,  resulting  from  the  passage  of,  or  retention  of,  sounds  and 
catheters,  has  been  so  severe  that  the  ejaculatory  ducts  have  either 
been  compressed  or  the  direction  of  their  orifices  has  been  thrown  so 
much  out  of  place  that  they  have  looked  backward  to  the  bladder. 
This  retroversion  of  the  orifices  may  be  partial  and  only  cause  them  to 
look  upward,  or  it  may  be  complete,  in  which  event  the  discharge  of 
semen  occurs  directly  backward. 

Displacement  of  the  ducts  and  of  the  prostate  has  been  known  to 
follow  abscesses  of  and  injury  of  the  perineum  (from  falls,  blows,  and 
infectious  processes),  which  caused  a  dense  fibrous  cicatricial  mass  to 
draw  that  gland  downward  and  to  much  distort  the  ano-perineal  and 
rectal  regions. 

In  tuberculous  inflammation  of  the  prostate  the  ejaculatory  ducts 
may  be  compressed  or  destroyed. 

In  old  men  these  canals  may,  when  the  prostate  becomes  hypertro- 
phied,  either  be  narrowed  or  entirely  stenosed. 

Calculi  and  concretions  in  the  prostate  may  cause  compression  or 
stenosis  of  the  ejaculatory  ducts.  It  is  probable  that  when  many  pros- 
tatic tubules  and  their  ducts  are  plugged  up  by  lime,  salts,  mucus,  and 
amyloid  bodies,  injurious  compression  may  be  exerted  upon  the  ducts. 

Abscess  of  the  prostate,  with  its  subsequent  cicatricial  development 
and  resulting  contraction,  may  utterly  obliterate  these  little  canals. 

Diminution  in  size  and  distortion  of  the  shape  of  the  organ  are 
generally  found  after  abscess  of  the  prostate. 

Perineal  fistula?  may  result  from  abscess  of  the  prostate,  and  in  this 
event  if  the  ejaculatory  ducts  be  not  obliterated  the  emission  will  prob- 
ably pass  through  the  false  passages  and  ooze  out  at  the  perineum. 

Permanent  aspermatism  may  result  from  injury  of  the  ejaculatory 
ducts  in  the  operations  of  lateral  or  bilateral  lithotomy. 

The  treatment  is  that  necessary  for  chronic  posterior  urethritis. 

HYPERTROPHY. 

In  a  goodly  number  of  men  at  and  beyond  fifty  years  of  age,  and 
perhaps  at  an  earlier  date,  the  prostate  gland  undergoes  a  peculiar  form 
of  enlargement,  generally  known  as  hypertrophy,  which  may  be  moder- 
ate in  size  or  it  may  reach  an  enormous  development.  This  morbid 
condition  is  found  in  a  variety  of  forms,  and  is  principally  important 
by  reason  of  the  mechanical  obstruction  which  it  causes  to  the  whole 
urinary  tract.  According  to  the  recent  extended  investigations  of  Al- 
banian  and    Halle    into  the   nature  of  the   growths   which   constitute 


308  AFFECTIONS  OF  THE  PROSTATE. 

hypertrophy  of  the  prostate,  the  principal  and  essential  lesion  is  glandu- 
lar hypertrophy  due  to  chronic  inflammation.  The  lesions  of  the  fibro- 
muscular  stroma  which  are  also  found  in  these  cases,  known  as  fibro- 
mvomatous  tumors,  are  secondary  and  may  form  a  greater  or  less  part 
of  the  enlargement.  In  some  few  cases,  however,  these  lesions  are 
found  to  predominate,  and  then  they  may  choke  the  glandular  hyper- 
trophy and  cause  it  to  disappear.  It  is  the  want  of  knowledge  of  these 
pathologic  facts  which  has  caused  some  authors  stoutly  to  maintain  that 
fibrp-myomatous  overgrowth  is  the  essential  process  in  prostatic  hyper- 
trophy. The  masses  of  glandular  hypertrophy  are  mostly  found  in  the 
triangular-shaped  posterior  median  space  (the  so-called  third  lobe) 
situated  between  the  two  lateral  lobes,  but  they  may  also  occur  in  the 
latter  structures. 

The  fibromatous  and  muscular  tissue  hypertrophy  may  be  inextrica- 
blv  scattered  throughout  the  gland,  causing  its  more  or  less  extensive 
enlargement ;  or  it  may  be  developed  in  the  form  of  distinct  round  or 
oval  tumors  having  a  capsule  of  fibrous  tissue.  These  tissues  may  be 
few  or  many  and  vary  in  size  from  that  of  a  small  shot  to  that  of  a 
marble  or  walnut. 

Glandular  and  fibro-myomatous  tumors  may  be  seated  in  the  substance 
of  the  gland,  or  may  be  more  superficially  placed,  when  they  may  pro- 
ject either  upon  its  urethral  or  bladder  surface,  or  on  both. 

An  extended  study  of  this  subject  in  its  clinical  aspect  and  in  its 
pathologic  results  has  convinced  me  that  hypertrophy  of  the  prostate  is 
found  in  four  quite  well-marked  forms,  as  follows  : 

Hypertrophy  of  one  or  both  of  the  lateral  lobes  of  the  prostate, 
without  median  enlargement. 

Hypertrophy  of  the  median  portion  of  the  prostate,  without  lateral 
enlargement.     (See  Plate VI.) 

Hypertrophy  of  lateral  portions  of  the  prostate,  with  the  formation 
of  a  bar.     (See  Plate  VII.) 

Hypertrophy  of  the  lateral  lobes  and  median  portion  of  the  prostate, 
the  latter  being  in  the  shape  of  a  sessile  or  more  or  less  pedunculated 
tumor.     (See  Plate  VIII.) 

These  abnormal  growths  produce  more  or  less  structural  change  in 
the  deep  urethra.  In  many  cases  the  mucous  membrane  becomes  verv 
much  swollen,  particularly  in  men  who  have  suffered  from  chronic 
gonorrhoea  or  from  chronic  inflammation  and  congestion  of  these  parts 
from  masturbation  and  sexual  excesses,  and  following  careless  and  inju- 
rious instrumentation. 

It  is  very  important  that  these  swollen  and  inflamed  conditions  of 
the  mucous  membrane  lining  the  prostatic  urethra  should  be  clearly 


PLATE  VI. 


HYPERTROPHY  OF  THE  LATERAL  PORTIONS  OF  THE  PROSTATE 

(the  right  one  being  the  seat  of  irregularly  shaped  tumors),  with  slight  enlargement 
of  the  median  portion.     Post-trigonal  pouch  clearly  shown. 


PLATE  VII. 


HYPERTROPHY  OF  THE  LATERAL  PORTIONS  OF  THE  PROSTATE, 
WITH  FORMATION  OF  A  BAR. 

(A  false  passage  has  been  made  through  the  bar.) 


PLATE  VIII. 


EXTENSIVE    HYPERTROPHY   OF   LATERAL   AND   MEDIAN 
PORTIONS    OF    THE    PROSTATE, 

the  latter  consisting  of  a  large  sessile  tumor. 


HYPERTROPHY.  309 

understood,  since  they  quite  early  cause  more  or  less  irritation  and 
difficulty  in  urination. 

When  the  lateral  lobes  are  enlarged,  particularly  when  one  lobe  is 
more  hypertrophied  than  the  other,  the  urethra  may  become  more  or  less 
distorted  and  deviated  in  its  course,  and  its  calibre  may  be  much 
decreased.  In  these  events  the  tissues  become  much  condensed  and  the 
normal  dilatability  of  the  prostate  and  its  urethral  segment  is  lost,  and 
the  urethral  canal  is  converted  into  an  unelastic  vertical  slit.  This 
abnormal  firmness  of  structure  of  the  prostate  may  gradually  tend  to 
produce  a  condition  of  patulousness  of  the  vesical  orifice  (the  internal 
sphincter  being  powerless),  which  can  never  close,  and,  as  a  result,  urine 
passes  into  the  prostatic  urethra. 

The  hyperplastic  processes  in  the  prostate  are  arrested  at  its  apex 
(which  may  be  more  or  less  enlarged)  by  reason  of  the  resistance  offered 
by  the  firm  triangular  ligament ;  therefore  when  hypertrophy  takes  place 
in  the  lateral  lobes  the  increase  is  mainly  towards  the  vesical  orifice. 
The  whole  organ  is  thereby  much  congested  (and  the  urethra  is  corre- 
spondingly elongated)  and  is  pushed  upward  and  rather  forward  into  the 
bladder.  As  a  result  the  vesical  orifice  is  elevated  above  the  base  of  the 
bladder  and  two  pouches  are  formed,  one  being  in  front  of  the  opening 
and  the  other  behind  it.  The  anterior  pouch  is  usually  small  and  of 
little  pathological  significance,  but  the  posterior  one  may  become  very 
large. 

As  a  consequence  of  the  prostatic  stenosis  and  the  dislocation  of  the 
vesical  orifice,  the  bladder  cannot  be  emptied  and  the  urine  lodges  in 
the  post-trigonal  pouch.  This  accumulation  of  residual  urine  gradually 
increases  in  quantity,  and,  as  it  does,  the  pouch  grows  larger,  so  that  a 
very  considerable  cavity  may  be  formed.     (See  Plate  VI.) 

Certain  structural  conditions  of  the  bladder  coexistent  with  hyper- 
trophy of  the  prostate  are  concerned  in  the  formation  of  the  post-trigo- 
nal pouch.  It  is  found  that  behind  the  trigonum  the  muscular  coat  of 
the  bladder  and  its  tissues  are  thin  and  weak.  Consequently  when  the 
viscus  contracts  and  the  urinary  stream  is  obstructed,  these  parts  gradu- 
ally yield  and  become  pouchy. 

At  the  same  time  that  these  structural  changes  are  taking  place  in 
the  base  of  the  bladder,  the  mucous  membrane  over  the  trigonum  be- 
comes congested  and  swollen,  and  this  tends  further  to  hinder  the  escape 
of  the  urine. 

Besides  the  tolerably  uniform  enlargement  of  the  lateral  lobes  so 
commonly  seen,  these  structures  may  be  the  seat  of  glandular  and  fibro- 
myomatous  tumors  which  jut  up  into  the  bladder  cavity  and  prostatic 
urethra.     There  may  be  one  or  many  of  these  growths  (see  Plate  VI.), 


310  AFFECTIONS  OF  THE  PROSTATE. 

which  may  vary  in  size  from  the  dimensions  of  a  bean  to  those  of  an 
orange.  In  some  rare  cases  very  large  tumors  springing  from  the  lat- 
eral lobes  have  been  found  to  project  above  the  pubes  and  to  seriously 
interfere  with  such  operations  as  suprapubic  cystotomy  or  vesical  aspi- 
ration. 

In  some  cases  the  enlargement  of  the  lateral  lobes  takes  place  toward 
the  rectum  and  acts  as  an  impediment  to  defecation.  In  some  of  these 
cases  no  interference  with  urination  is  observed,  owing  to  the  extra- 
urethral  development  of  the  hypertrophy,  while  in  others  the  urethra 
and  bladder  gradually  become  encroached  upon. 

Since  the  vesical  veins  empty  through  the  prostate  into  the  general 
circulation,  it  follows  that  condensation  of  the  gland  will  cause  com- 
pression of  these  vessels.  From  this  condition  there  results  in  many 
cases  a  state  of  congestion  of  the  bladder  and  of  the  prostate  gland, 
which  adds  greatly  to  the  seriousness  of  the  case. 

Two  forms  of  lesions  are  found  at  the  vesical  orifice  which  may  or 
may  not  coexist  with  enlargement  of  the  lateral  lobes.  These  lesions  are 
known  as  the  bar  at  the  neck  of  the  bladder  and  as  round  or  oval, 
sessile,  and  pedunculated  tumors  blocking  the  same  opening.  (See  Plates 
VII.  and  VIII.)  The  bar  at  the  neck  of  the  bladder  is  not  of  neces- 
sity due  to  prostatic  overgrowth.  It  is  formed  by  hyperplasia  occurring 
in  the  mucous  membrane  of  the  uvula  vesicae  seated  at  the  apex  of  the 
trigonum  and  between  the  two  lateral  lobes.  The  bar  consists  of  hyper- 
plastic mucous  membrane,  together  with  increased  growth  of  the  sub- 
mucous connective  tissue  and  of  more  or  less  unstriped  muscular  fibres. 
The  development  of  the  bar  may  be  slow  or  rather  rapid  and  it  soon 
interferes  with  micturition.  This  bar  is  well  shown  in  Plate  IV.,  in 
which  there  is  marked  enlargement  of  the  lateral  lobes.  It  also  will 
be  seen  that  a  false  passage  has  been  tunneled  through  the  base  of  the 
bar  and  into  the  lower  bladder  wall. 

The  pedunculated  and  sessile  tumors,  which  may  be  quite  small  or 
very  large,  are  formed  in  the  posterior  median  space  at  the  vesical  ori- 
fice. They  are  essentially  true  prostatic  overgrowths.  There  is  usually 
but  one,  and  exceptionally  several  are  found.  These  tumors  begin  with 
the  hypertrophy  of  the  mass  of  gland-tissue,  which  is  enveloped  in  a 
rich  connective-tissue  stroma  and  covered  with  mucous  membrane.  This 
glandular  mass  in  young  men  is  frequently  the  seat  of  chronic  inflam- 
mation, and,  as  years  roll  by,  so  great  is  the  resulting  hyperplasia  that 
a  tumor,  as  above  described,  is  formed  which  has  been  wrongly  called  the 
third  lobe  of  the  prostate. 

As  this  glandular  mass  increases  in  size,  it  projects  into  the  bladder 
more  and  more  until  it  may  hang  over  the  vesical  orifice  like  a  valve, 
and  this  interferes  with  or  wholly  prevents  the  escape  of  urine  from  the 


PLATE   IX. 


TRABECULATIONS  AND  SACCULATIONS  OF  THE  BLADDER. 


PLATE  X. 


DIVERTICULUM    OF    BLADDER. 


PLATE  XI. 


HYPERTROPHY  OF  LATERAL  AND  MEDIAN  PORTIONS 
OF  THE  PROSTATE, 

the  latter  being  in  the  form  of  a  pedunculated  tumor  on  posterior  wall 
of  bladder  (villous  growths  encrusted  with  phosphatic  salts). 


SYMPTOMS  OF  HYPERTROPHY.  311 

bladder.  The  impediment  to  urination  caused  by  the  bar  at  the  neck, 
by  the  pedunculated  tumors  which  act  like  valves,  and  by  the  greater 
or  less  stenosis,  and  perhaps  by  the  tortuosity  of  the  prostatic  urethra, 
react  upon  the  bladder  and  produce  in  it  further  important  structural 
changes.  In  some  cases  this  viscus  becomes  gradually  dilated  and 
thinned  from  atrophy  until  its  holding  capacity  is  far  greater  than 
normal ;  while  in  others  an  increasing  condensation  and  hypertrophy 
of  the  entire  bladder-wall  structure  and  its  perivesical  connective  tissue 
takes  place  and  its  cavity  is  then  rendered  smaller,  until  in  the  end  it 
may  only  hold  a  few  ounces  of  urine. 

With  the  increasing  interference  with  urination,  the  muscular  fibres 
of  the  bladder  may  become  much  hypertrophied,  so  that  a  striking  con- 
dition of  trabeculation  upon  the  internal  vesical  surface  is  produced. 
(See  Plate  VI.)  In  this  trabeculated  condition  of  the  bladder,  protru- 
sions of  the  mucous  membrane  from  between  the  bands  of  hypertrophied 
muscular  fibres  and  pouches  may  be  developed.  (See  Plate  IX.)  In 
very  severe  cases  true  sacculi  or  diverticula  (see  Plate  X.)  are  formed 
which  are  usually  multiple,  and  may  be  of  the  size  of  a  walnut  or  of  an 
orange,  or  they  may  be  even  larger  than  the  bladder  itself. 

In  many  cases  when  these  severe  degenerative  changes  take  place, 
ulceration  of  the  mucous  membrane  covering  the  prostatic  overgrowths 
may  develop  and  cause  much  suffering  for  the  patient.  In  addition  to 
these  changes  in  the  structure  of  the  bladder,  it  is  necessary  to  remem- 
ber the  post-trigonal  pouch  already  described.     (See  Plate  VI.) 

In  many  cases  of  hypertrophy  with  residual  urine,  calculi  are  prone 
to  form.  These  stones  may  give  rise  to  no  symptoms  whatever,  since 
they  are  situated  low  down  in  the  bladder,  below  and  behind  the  trigo- 
num,  and  in  urination  are  not  pushed  against  the  very  irritable  vesical 
orifice.  In  some  severe  cases  benign  and  malignant  tumors  cause  for- 
midable complications.  In  Plate  XL  villous  growths  encrusted  with 
phosphatic  salts  are  well  shown. 

In  many  cases  of  prostatic  enlargement  there  is  synchronous  conges- 
tion of  the  rectum,  and  hemorrhoids  are  developed  which  very  often 
greatly  aggravate  and  complicate  the  case. 

Symptoms. — The  symptoms  of  hypertrophy  of  the  prostate  vary 
somewhat  according  to  the  part  of  the  organ  which  is  the  seat  of  en- 
largement and  to  the  early  or  late  involvement  of  the  prostatic  urethra. 

In  cases  in  which  the  hypertrophy  begins  in  the  outer  and  posterior 
portion  of  the  gland,  the  symptoms  may  be  slow  in  development  and 
will  not  be  very  well  marked  until  the  calibre  of  the  prostatic  urethra 
is  rendered  smaller,  or  until  its  mucous  membrane  has  become  con- 
gested, swollen,  and  irritable.  Many  men  never  have  symptoms  of 
hypertrophy  of  the  prostate,  for  the  reason  that  the  new  cell-growths 
are  developed  at  a  distance  from  the  prostatic  urethra,  which  does  not 


312  AFFECTIONS   OF  THE  PROSTATE. 

become  stenosed.  On  the  other  hand,  when  the  enlargement  occurs  in 
the  lateral  lobes,  particularly  when  rather  near  the  prostatic  urethra, 
the  symptoms  may  develop  rather  slowly  and  insidiously  or  quite 
rapidly.  Then,  again,  in  the  cases  in  which  the  hypertrophy  begins  in 
the  so-called  third  lobe,  or  when  the  vesical  bar  is  developing,  the 
symptoms  are  observed  to  appear  more  or  less  promptly. 

The  condition  of  the  prostatic  urethra  before  the  onset  of  the  hyper- 
trophy has  much  to  do  with  the  mildness  or  the  severity  of  the  initial 
symptoms.  With  the  increase  in  the  structural  elements  of  the  pros- 
tate, there  is  developed  a  chronic  and  hyperplastic  congestion  of  the 
urethral  mucous  membrane,  which  acts  as  an  impediment  to  urination. 

"When  the  prostatic  mucous  membrane  is  normal  prior  to  the  onset 
of  the  hypertrophy,  this  segment  of  the  urethra  may  not  for  a  time 
give  rise  to  symptoms  of  marked  severity  beyond  a  slight  impediment 
to  urination,  for  the  reason  that  there  is  very  little  irritability  of  the 
parts.  But  in  cases  of  chronic  posterior  urethritis  the  involvement  of 
this  segment  of  the  canal  occurs  quite  early  and  the  symptoms  are 
promptly  developed. 

In  some  cases  difficulty  in  urination  is  the  first  symptom  complained 
of,  while  in  many  others  increased  frequency  of  the  act  is  the  first  and 
the  most  constant  phenomenon.  This  symptom  is  especially  well 
marked  at  night  and  early  in  the  morning,  when  the  recumbent  position 
tends  to  produce  congestion  of  the  bladder  and  prostate.  But  as  the 
case  progresses  diurnal  frequency  of  urination  is  also  observed.  At 
first  the  patient  may  pay  little  attention  to  this  symptom  and  look  upon 
it  as  an  unimportant  sign  of  advancing  age,  but  when  the  intervals  of 
urination  become  shorter  and  when  the  slight  initial  pain  becomes  more 
severe,  and  the  patient's  sufferings  and  discomfort  more  marked,  he 
realizes  that  something  is  radically  wrong  with  him. 

The  difficulty  in  urination  may  increase  very  slowly  or  quite  rapidly. 
Patients  complain  that  they  experience  difficulty  in  starting  the  urine, 
and  that  when  it  begins  it  has  little  force.  It  is  noticed  then  that  the 
stream  is  decreased  in  size  as  well  as  in  force,  and  that  it  is  feeble  and 
halting.  Towards  the  end  of  the  act,  there  is  more  or  less  feeble  drib- 
bling. All  these  symptoms  depend  upon  the  urethral  stenosis,  the 
atony  of  the  walls  of  the  bladder,  and  a  condition  of  spasm  of  the  com- 
pressor urethra?  muscle. 

As  a  rule,  the  cases  of  bar  or  tumor  at  the  vesical  orifice  are  for 
obvious  reasons  the  ones  which  suffer  earliest  and  more  severely  from 
difficult  urination.  "When  the  vesical  pouch  is  yet  small  and  the  residual 
urine  clean  and  limited  in  amount,  the  symptoms  may  be  rather  mild. 
"With  the  increase  in  the  residuum,  decomposition  of  the  urine  may 
occur  and  severe  symptoms  may  result.     The  urine,  if  normal  in  the 


SYMPTOMS   OF  HYPERTROPHY.  313 

beginning,  promptly  becomes  more  or  less  opaque  from  the  intermixture 
of  pus.  In  cases  of  chronic  posterior  urethritis,  pyuria  is  an  early 
symptom. 

The  stagnation  of  purulent  urine  in  the  bladder  further  reacts  on  its 
walls  and  also  on  the  mucous  membrane  of  the  prostatic  urethra,  and 
as  a  result  these  tissues  become  inflamed,  irritable,  and  painful ;  and  in 
consequence,  the  desire  for  urination  is  still  more  frequent  and  imper- 
ative. With  the  continuance  of  the  pyuria,  the  urine  becomes  much 
decomposed,  alkaline  from  decomposition  of  the  urea,  loaded  with  ropy 
pus,  and  of  very  offensive  odor.  In  this  state,  calculi  may  form  in  the 
post-trigonal  pouch,  and  phosphatic  concretion  may  develop  in  the 
trabeculations  and  in  the  sacculi  or  diverticuli  and  perhaps  on  the  exco- 
riated or  ulcerated  spots.  When  cases  have  progressed  to  this  serious 
state,  the  inflammatory  and  infective  processes  may  spread  up  the 
ureters  and  involve  the  pelves  of  the  kidneys  and  the  parenchyma  of 
these  organs.  In  many  cases  patients  suffer  from  mild  or  severe  pain 
in  the  penis,  particularly  at  the  glans,  and  in  the  testes  and  scrotum. 
There  also  may  be  dull,  aching  pains  in  the  perineum,  bladder,  and 
rectum,  particularly  when  the  body  is  jolted.  Many  patients  complain 
of  uneasy  sensations  and  of  dull  pains  in  the  sacral,  hypogastric, 
and  lumbar  regions,  which  they  wrongly  attribute  to  rheumatism  and 
lumbago. 

In  somewhat  exceptional  cases,  the  bladder  walls  become  enormously 
thickened  and  the  bladder  cavity  contracts  until  it  holds  little  if  any 
urine.  The  vesical  symptoms  are  usually  quite  severe,  the  bladder 
becomes  very  irritable  when  only  a  small  amount  of  urine  is  secreted, 
the  desire  to  urinate  is  incessant,  and  the  pain  very  great.  There  is  no 
residual  urine  in  these  cases. 

In  many  cases  of  hypertrophy,  hematuria  occurs.  It  may  be  mild 
or  severe  in  character.  Its  occurrence  may  be  infrequent  or  it  may  be 
very  persistent.  Occasionally  the  passage  of  instruments,  even  when 
carefully  introduced,  gives  rise  to  hemorrhage,  while  in  many  cases  the 
strong  and  constant  expulsive  efforts  of  the  bladder  cause  blood  to 
exude  from  the  excoriated  or  ulcerated  surface. 

Retention  of  urine  is  a  not  infrequent  complication  of  hypertrophy 
of  the  prostate,  and  depends  upon  two  conditions,  viz. :  increased  con- 
gestion of  the  bladder  and  prostatic  urethra,  and  spasm  of  the  com- 
pressor urethrte  muscle.  It  is  apt  to  come  on  suddenly  and  without 
warning,  and  may  cause  much  vesical  distention.  The  exciting  causes 
are:  catching  cold;  errors  in  diet;  intestinal  distention;  alcoholic 
excess ;  ingestion  of  too  much  fluid  ;  constipation  ;  over-exertion  and 
physical  exhaustion  ;  sexual  excesses  ;  and  operations  upon  the  anus, 
rectum,  and  external   genitals.     Retention   of  urine  in  prostatic  cases 


314  AFFECTIONS  OF  THE  PROSTATE. 

may  be  caused  by  the  lodgement  of  a  stone  or  tumor  near  the  vesical 
orifice,  in  which  it  becomes  engaged  or  impacted,  having  been  carried 
by  the  urinary  stream. 

In  many  cases,  when  retention  of  urine  is  not  promptly  relieved,  the 
compressor  urethra?  muscle  becomes  weak  and  loses  its  tonicity  and  con- 
tractile power.  Then  the  urine  begins  to  dribble,  but  the  residuum  yet 
remains.  This  condition  has  been  termed  incontinence,  but  it  is  really 
urinary  overflow. 

Prostatic  hypertrophy  may  be  aggravated  by  the  congestion  which 
sometimes  occurs  as  the  result  of  troublesome  hemorrhoids. 

In  some  cases,  during  the  course  of  prostatic  hypertrophy,  there  is 
more  or  less  severe  sexual  erethism,  which  usually  occurs  when  the 
patient's  general  condition  becomes  much  lowered. 

Hernia  or  prolapse  of  the  rectum  is  sometimes  produced  by  the  vio- 
lent straining  in  urination. 

Such  testicular  complications  as  congestion  or  suppurative  inflamma- 
tion of  the  epididymes,  testes,  and  tunica  vaginalis  not  infrequently 
occur.  A  mucoid  and  purulent  discharge  from  the  urethra  is  a  not  un- 
common symptom. 

What  is  known  as  catheter  fever  is  sometimes  observed  in  the  course 
of  hypertrophy  of  the  prostate.  This  condition  may  be  caused  by  in- 
strumentation which  damages  the  prostatic  urethra  or  bladder.  Within 
a  short  time  after  the  traumatism  the  patient  becomes  chilly  and  suffers 
from  malaise.  The  temperature  at  first  may  be  subnormal,  but  it  soon 
rises.  The  fever  is  of  rather  a  mild  type,  either  continuous  or  inter- 
mittent, and  is  usually  of  short  duration. 

With  the  increasing  impediment  to  urination,  the  severity  of  the 
local  lesions  in  the  prostate  and  bladder,  and  the  advancing  disorgani- 
zation of  the  kidneys,  the  health  of  the  patient  gradually  declines, 
albuminuria  and  polyuria  being  constant  concomitants.  The  desire  to 
urinate  becomes  more  severe  and  imperative  and  the  interval  very  short. 
The  patient  suffers  from  constant  tenesmus,  and  is  only  able  to  discharge 
a  few  drops  of  scalding  urine  which  causes  acute  pain.  He  suffers  from 
mental  anxiety,  headache,  sleeplessness,  weakness,  dyspepsia,  and  pro- 
gressing emaciation.  His  cystitis  causes  urinary  poisoning,  and  his 
kidney  lesions  prevent  elimination  of  the  urea,  and  uraemia  is  developed. 
He  suffers  from  a  peculiar  dry  tongue,  and  his  breath  has  a  urinous 
odor. 

In  this  condition  severe  chills  and  fever  very  often  intervene  and 
add  to  the  patient's  misery.  Death  usually  results  from  exhaustion, 
septicaemia,  and  uraemia. 

The  Diagnosis  of  Hypertrophy  of  the  Prostate. — The  diagnosis 
of  prostatic  hypertrophy  is   readily  made  from  a  careful  consideration 


SYMPTOMS   OF  HYPERTROPHY.  315 

of  the  patient's  symptoms,  together  with  a  urinary,  urethral,  bladder, 
and  prostatic  examination,  the  latter  being  conducted  both  by  way  of 
the  rectum  and  the  bladder. 

The  previous  history  of  the  case  being  noted  carefully  in  every 
detail,  both  sexual  and  urinary,  the  patient  is  asked  to  stand  and  void 
his  urine.  This  being  done,  the  surgeon  passes  a  small,  soft-rubber 
catheter  and  draws  what  remains  in  the  bladder  (the  residuum),  noting 
the  depth  at  which  the  urine  is  drawn,  which  gives  the  urethral  length. 
The  catheter  also  imparts  to  the  fingers  the  condition  of  the  deep 
urethra.  The  amount  of  the  residual  urine  being  measured,  it  is 
mixed  with  that  spontaneously  voided,  and  the  specimen  examined  for 
urethral  and  bladder  conditions  and  kidney  complications.  In  order 
to  get  a  correct  idea  as  to  the  real  amount  of  the  residual  urine,  the 
surgeon  should  always  wait  until  the  patient  has  a  normal  desire  to 
urinate  and  never  force  him  to  hurry  the  act.  The  character  and 
force  of  the  stream  should  be  carefully  observed,  botli  on  catheteriza- 
tion and  urination,  which  gives  us  some  idea  as  to  the  bladder  muscu- 
lature. The  residuum  being  drawn,  it  must  be  replaced  immediately 
with  an  equal  amount  of  warm  boric-acid  solution,  some  of  which 
should  flush  out  the  urethra  as  the  catheter  is  withdrawn. 

The  patient  being  on  his  back,  or  standing  upright  with  body  flexed 
and  hands  resting  on  a  chair,  the  prostate  is  examined  by  rectal  touch 
which  imparts  to  the  finger  the  size  and  consistence  of  the  gland,  its 
degree  of  sensitiveness,  and  also  the  condition  of  the  base  of  the  bladder 
and  the  rectal  mucous  membrane.  The  finger  first  impinges  against 
the  blunt  and  rounded  apex  of  the  gland,  then  sweeps  from  the  side 
over  its  rounded  borders,  and  finally  endeavors  to  hook  over  its  more 
or  less  thickened  base.  In  a  general  way,  the  enlarged  prostate  feels 
somewhat  like  a  triangular  mass,  with  rounded  angles  and  borders, 
whose  blunted  apex  joins  the  membranous  urethra,  its  base  being 
directed  upward. 

The  amount  and  character  of  prostatic  overgrowth  into  the  deep 
urethra  and  bladder  can  only  be  ascertained  by  instrumental  examina- 
tion of  these  parts,  and  must  always  be  conducted  in  the  most  gentle 
and  conservative  manner,  as  traumatism  of  the  now  congested  deep 
urethra  is  apt  to  be  followed  by  serious  and  even  fatal  results.  The  ex- 
amination can  be  conducted  under  cocaine  or  eucaine  anesthesia,  with 
soft  bougies  a  boule,  olivary  bougies,  coude  catheters,  and  stone-search- 
ers, which  impart  to  the  examiner  the  amount  of  deviation  either  to  the 
right  or  left,  and  the  loss  of  calibre  of  the  prostatic  urethra.  A  bar  or 
prostatic  projection  at  the  vesical  neck  is  recognized  by  the  degree  of 
depression  of  its  handle  necessary  to  carry  a  curved  instrument  over  it, 
which  when  in   the  bladder  can  be  inverted  and  its  tip  made  to  sweep 


316  AFFECTIONS  OF  THE  PROSTATE. 

through  the  post-trigonal  pouch,  where  stones  are  not  infrequently 
found.  At  the  same  time  the  condition  of  the  bladder-walls  can  be 
ascertained  by  passing  the  instrument  gently  over  them,  which  will 
show  whether  they  are  smooth,  rugous,  or  trabeculated. 

It  may  sometimes  be  considered  wise  and  even  necessary  to  examine 
the  overgrowth  and  bladder  with  the  cystoscope  ;  but  this  should  not 
be  carried  out  as  a  routine  method,  but  reserved  for  certain  rare  and 
exceptional  cases,  in  which  tumor  or  stone  is  suspected  and  cannot  be 
found  by  other  methods. 

The  presence  of  urethral  stricture,  which  sometimes  complicates  and 
aggravates  prostatic  hypertrophy,  is  best  ascertained  by  soft  bougies 
a  boule. 

On  account  of  the  age  of  the  patient,  the  congested  condition  of  the 
parts,  the  susceptibility  to  infection,  and  the  possible  kidney  complica- 
tions, the  surgeon  must  always  be  as  gentle  and  cleanly  in  his  exami- 
nation as  possible,  which  should  never  be  too  long  or  exhaustive  at  the 
first  consultation. 

The  Treatment  of  Hypertrophy  of  the  Prostate. — Palliative 
Teeatmext. — These  patients  must  live  moderate'  and  regular  lives, 
being  careful  not  to  expose  themselves  to  cold  and  wet,  or  to  do  any- 
thing that  will  congest  and  irritate  the  urinary  and  sexual  tract.  Their 
sexual  relations  must  be  moderate  and  regular,  always  avoiding  ungrati- 
fied  sexual  excitement.  They  should  always  urinate  when  the  desire 
comes  on  and  never  try  to  hold  the  urine  after  this  time.  They  can 
drink  freely  of  any  bland  wrater,  but  must  be  moderate  in  the  use  of 
alcohol,  taking  a  little  whiskey  with  meals,  if  indicated,  but  avoiding 
all  other  alcoholic  beverages  ;  coffee  should  be  taken  weak  and  but  once 
a  day.  Any  article  of  diet  that  causes  urinary  irritation  must  be 
strictly  prohibited.  The  bowels  are  to  be  regulated  and  hemorrhoids 
treated  in  an  appropriate  manner  according  to  their  severity.  As  these 
patients  urinate  more  freely  when  they  are  up  and  about,  they  should 
exercise  intelligently  in  the  open  air  and  sunshine,  and  keep  the 
secretory  apparatus  of  the  skin  in  working  order  by  means  of  baths, 
rubbings,  and  massage.  Internal  medication  depends  entirely  upon  the 
reaction  of  the  urine,  which  should  be  kept  as  normally  acid  as  possi- 
ble, and  for  this  purpose  there  is  no  better  preparation  than  urotropin, 
given  in  seven-grain  doses  three  times  a  clay.  Cystogen  is  likewise 
said  to  act  in  a  very  satisfactory  manner,  as  is  also  boric  acid  alone  or 
combined  with  salol  or  tincture  of  hyoscyamus.  Dilute  nitric  and  nitro- 
muriatic  acid  may  be  given  in  suitable  doses.  If,  on  the  other  hand, 
the  urine  seems  too  acid,  we  may  employ  bicarbonate  of  soda,  or  the 
acetate,  citrate,  or  bicarbonate  of  potash. 

The  hot  sitz-bath,  or  hot  rectal  irrigations  of  normal  salt  solution, 


TREATMENT  OF  HYPERTROPHY.  317 

act  in  a  very  beneficial  manner  in  reducing  the  prostatic  congestion  and 
its  concomitant  symptoms,  and  should  always  be  tried  in  these  cases. 
Suppositories  of  ichthyol  sometimes  act  in  a  similar  manner.  For  pain 
and  tenesmus  we  may  sometimes  have  to  resort  to  the  guarded  and  in- 
telligent use  of  small  doses  of  ctfdeine,  opium,  morphine,  and  bella- 
donna, either  by  the  mouth  or  rectum.  Strychnine,  quinine,  and  tonics 
in  general  are  indicated  in  run-down  and  debilitated  subjects. 

Gentle  prostatic  massage  may  be  employed  in  certain  cases  with 
benefit,  but  should  never  be  practised  in  a  routine  manner  or  if  pyuria 
is  marked  and  the  prostate  acutely  congested,  these  conditions  being 
greatly  benefited  by  rectal  irrigations  of  hot  water. 

Catheter  life,  by  which  is  understood  the  regular  evacuation  of 
the  bladder,  is  instituted  with  the  view  of  relieving  that  viscus  of  its 
residuum  which  by  its  presence  increases  the  post-prostatic  pouch,  thus 
rendering  urination  more  frequent  and  difficult  and  cystitis  with  possi- 
ble stone  formation  more  certain.  The  time  to  begin  the  use  of  the 
catheter  rests  largely  upon  the  surgeon's  common  sense  and  good  judg- 
ment, and  no  definite  and  infallible  rules  can  therefore  be  made. 
When,  however,  the  frequency  is  marked  and  the  patient  has  several 
ounces  of  residuum,  it  is  best  to  begin  gentle  catheterization  with  soft 
and  sterile  instruments,  providing  we  cannot  relieve  his  condition  by 
means  of  the  previously  described  methods  of  treatment.  We  should 
always  select  the  smallest  and  softest  catheter  that  will  enter,  be  sure 
that  it  is  clean,  and  pass  it  with  the  utmost  care  and  gentleness,  say 
once  in  twenty-four  hours,  or  oftener  if  indicated  by  a  larger  residuum. 
The  urine  being  drawn,  the  surgeon  can  then  irrigate  the  bladder  and 
prostatic  urethra  with  a  few  ounces  of  warm  boric  acid,  salt,  zinc,  alum, 
or  permanganate  of  potassium  solution,  leaving  a  little  in.  Later  can  be 
used  boroglyceride  (5j  to  3ij  to  water  Ixvj),  iodine  trichloride  1  to  3000, 
salicylic  acid  (gr.  -|  to  §j),  and,  best  of  all,  nitrate  of  silver  either  in 
instillations  or  irrigations.  When  the  urine  is  clear  and  transparent,  and 
contains  flakes  (tissue  elements),  only  then  instillations  of  nitrate  of 
silver  beginning  with  1  to  4000  are  to  be  used  ;  if,  on  the  other  hand, 
the  urine  is  cloudy  from  pus  and  mucus,  then  irrigations  of  nitrate  of 
silver,  beginning  with  1  to  16,000,  are  required,  as  more  surface  has  to 
be  acted  on.  By  these  means  we  endeavor  to  check  the  urethro-cystitis, 
to  restore  the  mucous  membrane  of  the  bladder  and  deep  urethra  to  a 
fairly  normal  condition,  and  to  reduce  the  size  and  sensitiveness  of  the 
enlarged  prostate  gland,  all  of  which  are  possible  in  many  cases  if  the 
surgeon  is  skilful  and  patient  and  avoids  all  traumatism  of  the  deep 
urethra  and  bladder. 

If  frequency  is  very  marked,  causing  the  patient  to  be  up  many 
times  during  the  night,  a  catheter  can  be  tied  in  at  bedtime,  which  will 


318  AFFECTIONS  OF  THE  PROSTATE. 

keep  the  bladder  drained  and  in  some  cases  enable  the  patient  to  get  a 
good  night's  rest ;  in  others,  however,  it  cannot  be  retained  on  account 
of  the  irritation  it  produces. 

Suprapubic  drainage  will  give  immediate  but  only  temporary  relief 
in  prostatics  suffering  from  long  retention  of  urine  with  subsequent 
pain,  congestion,  and  tenesmus,  so  it  should  only  be  resorted  to  as  a  pal- 
liative measure  or  until  something  of  a  radical  nature  can  be  under- 
taken. There  is  always  more  or  less  leakage  of  urine  around  the  tube, 
which  keeps  the  patient  in  a  most  uncomfortable  and  offensive  condi- 
tion. Perineal  drainage  is  not  to  be  advised.  Forcible  dilatation  of 
the  prostatic  urethra,  either  with  sounds  or  specially  constructed  instru- 
ments, is  merely  mentioned  to  be  condemned,  on  account  of  the  trau- 
matism to  the  mucous  membrane  of  the  deep  urethra  and  the  almost 
certain  development  of  urinary  infection. 

Operative  Treatment. — So  long  as  catheterization  is  easy  and  pain- 
less, the  residuum  small  and  clear,  the  obstruction  to  urination  moderate, 
and  the  bladder  musculature  acts  in  a  satisfactory  manner,  the  surgeon 
should  advise  against  operation,  since,  with  appropriate  internal  medi- 
cation and  local  applications  given  by  means  of  soft-rubber  instruments, 
we  can  so  improve  the  congested  condition  of  the  parts  that  these 
patients  may  live  for  years  in  comfort ;  so  that  as  a  result  of  this  treat- 
ment the  number  of  cases  demanding  operation  will  be  materially  re- 
duced, if  seen  at  an  early  date.  When,  however,  palliative  treatment 
fails  to  give  relief  and  to  prevent  the  further  progress  of  the  disease — 
viz. :  increase  of  obstruction,  with  frequent,  painful,  and  difficult  cathe- 
terization, uncontrollable  cystitis,  and  increasing  residuum — it  is  time 
to  consider  some  form  of  operative  interference  best  suited  to  the  re- 
quirements of  each  individual  case. 

The  selection  of  an  appropriate  operation  is  all-important,  and  can 
only  be  decided  on  by  the  surgeon,  who  must  be  guided  entirely  by  the 
results  of  his  examination  and  his  personal  experience  and  judgment  in 
such  cases,  since  no  particular  operation  is  applicable  to  all  cases  of 
hypertrophy  demanding  operative  intervention. 

The  following  are  the  operations  now  performed  for  the  relief  of  pros- 
tatic hypertrophy  and  obstruction  : 

Prostatotomy  consists  of  the  division  of  the  obstruction  at  the 
vesical  orifice,  either  with  cutting  instruments  (prostatomes)  or  with 
specially  constructed  galvano-caustic  instruments  (Bottini),  the  over- 
growth being  attacked  through  the  perineum  or  by  way  of  the  urethra. 

Perineal  Prostatotomy. — The  patient  is  placed  in  the  lithotomy  posi- 
tion and  a  tunneled  sound  is  passed,  the  urethra  being  opened  on  its 
convexity  at  the  apex  of  the  prostate,  whose  urethra  is  overdilated  by 
the  index-fino;er.     The  obstruction  at  the  vesical  orifice  is  incised  with  a 


TREATMENT  OF  HYPERTROPHY 


319 


blunt    bistoury,    and    a    large,    soft-rubber    perineal    tube    inserted    for 
drainage.     This  operation  is  to  be  strongly  condemned,  as  the  surgeon 
cannot  see  what  he  is  doing ;  the  perineal  wound  is  small        F      R, 
and  difficult  to  operate  upon,  and  hemorrhage  is  apt  to 
be  free  and  not  easily  controlled. 

Urethral  prostatotomy  has  been  performed  by  a  limited 
number  of  operators  with  special  cutting  instruments 
(prostatomes),  but  it  has  never  been  endorsed  and  prac- 
tised by  surgeons  in  general,  and  is  at  best  an  antiquated 
and  hazardous  procedure,  no  longer  to  be  employed. 

Bottini's  galvano-caustic  operation  is,  strictly  speak- 
ing, urethral  prostatotomy,  the  operator  burning  one  or 
more  grooves  through  the  obstruction  by  means  of  Freu- 
denberg's  modification  of  Bottini's  incisor.     (See  Fig.  81.) 

Before  performing  Bottini's  operation,  the  surgeon 
should  make  a  cystoscopic  examination  of  the  bladder  to 
ascertain  the  condition  of  its  walls,  the  conformation  of 
the  prostatic  enlargement,  and  perhaps  the  presence  of 
an  overlooked  stone.  The  prostate  should  also  be  ex- 
amined by  rectal  touch.  The  patient  is  placed  on  his 
back  and  the  bladder  and  urethra  irrigated  with  salt 
solution,  several  ounces  of  which  should  be  retained  (air 
has  also  been  employed  for  vesical  distention).  The 
urethra  is  anaesthetized  with  eueaine  solution,  thus  ren- 
dering the  operation  practically  painless.  The  battery 
and  incisor  are  now  tested  to  ascertain  the  current  needed 
to  bring  the  platinum  blade  to  a  white  heat.  The  cooling 
apparatus  is  also  tested.  The  incisor,  being  in  working 
order,  is  passed  into  the  bladder  in  the  usual  manner; 
the  beak  of  the  instrument  is  now  turned  down  into  the 
post-prostatic  pouch  and  pulled  forward  so  that  its  con- 
cave surface  presses  against  the  obstruction.  The  cooling 
apparatus  is  started,  the  current  turned  on,  and,  after  a 
few  seconds,  in  order  to  be  certain  that  the  blade  is  white- 
hot,  the  wheel  at  the  handle  is  turned  very  slowly,  the 
operator  noting  on  the  scale  the  length  of  the  cut.  When 
this  is  satisfactory,  the  blade  is  returned  to  the  groove  in 
the  female  shank.  The  current  is  then  turned  off.  If  it  is 
deemed  necessary  to  burn  through  one  or  both  of  the  lateral 
lobes,  the  beak  of  the  incisor  is  turned  upward  and  the  burn-      Freudenberg  s 

'  i  modification    of 

ing  is  accomplished  as  already  described.  The  operation  Bottini's  incisor, 
being  completed,  the  current  is  turned  off,  the  blade  allowed  to  cool,  and 
the  instrument  withdrawn.     The  patient  is  put  to  bed  and  allowed  to 


320  AFFECTIONS   OF  THE  PROSTATE. 

urinate  if  he  can,  otherwise  he  must  be  catheterizecl  when  necessary 
and  the  bladder  irrigated  if  it  is  deemed  advisable.  Apparently  simple 
as  the  above  operation  is,  it  must  be  remembered  that  it  is  done  in  the 
dark,  and  that  it  may  be  followed  by  hemorrhage,  epididymitis,  abscess 
of  the  prostate,  sepsis,  pyaemia,  and  even  embolism  of  the  pulmonary 
artery  ;  in  other  words,  the  bladder  does  not  have  the  free  drainage 
which  is  so  essential  in  this  class  of  cases,  the  obstruction  not  being 
removed  at  the  time  of  operation.  It  may  prove  of  value  in  a  limited 
number  of  carefully  selected  cases,  but  must  not  be  undertaken  lightly 
when  cystitis  is  marked  and  the  kidneys  in  a  damaged  condition.  It 
is  too  early  as  yet  to  speak  definitely  as  to  the  permanency  of  the 
results  and  the  exact  class  of  cases  to  which  it  is  best  suited. 

Prostatectomy  consists  of  the  partial  or  complete  removal  of  the 
gland,  either  through  a  perineal  incision  or  by  the  usual  suprapubic 
operation. 

Perineal  prostatectomy  as  modified  by  Alexander  is  performed  as  fol- 
lows :  The  patient  being  on  his  back,  a  small  suprapubic  cystotomy 
is  performed,  the  wound  being  made  just  large  enough  to  admit  two 
fingers  ;  the  patient  is  then  placed  in  the  lithotomy  position  and  a 
tunneled  sound  passed,  on  the  convexity  of  which  the  membranous 
urethra  is  opened  in  the  usual  manner.  The  sound  is  then  removed  and 
the  prostate  pressed  down  into  the  perineal  wound  by  two  fingers  in 
the  bladder,  the  capsule  of  the  prostate  is  opened  at  its  apex,  and  the 
gland-  shelled  out  by  the  fingers  and  blunt  forceps ;  first  the  lateral 
portions,  and  finally  the  posterior  median  lobe.  The  removal  of  the 
gland  can  sometimes  be  expedited  by  seizing  the  prostate  with  forceps 
and  holding  it  well  down  in  the  wound.  Hemorrhage  is  usually  quite 
severe.  The  bladder  is  drained  both  by  the  suprapubic  and  perineal 
wounds.  Alexander  sometimes  performs  this  operation  without  the  aid 
of  the  suprapubic  cystotomy  incision. 

Suprapubic  prostatectomy  is  the  operation  to  be  chosen  in  the  great 
majority  of  cases  demanding  operative  relief,  as  the  overgrowth  can  be 
inspected,  hemorrhage  readily  controlled,  and  calculi  removed  without 
adding  any  risk  to  the  operation.  Suprapubic  cystotomy  having  been 
performed  in  the  usual  manner  (see  page  376),  the  wound  is  stitched  to 
the  parietal  incision.  The  patient  can  now  be  placed  in  the  Trendelen- 
burg position,  or  left  on  his  back.  The  edges  of  the  wound  being  well 
retracted,  the  prostate  is  inspected  by  aid  of  an  electric  light,  and  care- 
fully palpated,  after  which  the  projecting  portions  and  as  much  of  the 
gland  are  removed  as  is  necessary  to  restore  the  normal  calibre  and 
level  of  the  floor  of  the  prostatic  urethra.  The  portions  of  the  gland 
are  enucleated  with  the  finger  or  forceps  through  one  or  more  incisions 
made  through  the  bladder  mucous  membrane.     The  hemorrhage  is  usu- 


TREATMENT  OF  HYPERTROPHY.  321 

ally  so  free  that  the  surgeon  can  see  nothing  and  has  to  rely  on  touch 
alone.  This  part  of  the  operation  must  be  done  most  carefully,  always 
bearing  in  mind  to  do  as  little  tearing  and  cutting  as  possible.  The 
hemorrhage,  when  quite  severe,  can  be  controlled  by  very  hot  irrigations 
of  saline  solution  thrown  into  the  suprapubic  wound,  combined  with 
packing  the  bladder,  or,  better  still,  the  application  of  a  Keyes  pad, 
passed  through  the  wound  into  the  bladder  and  held  firmly  against  its 
bleeding  base  by  a  heavy  silk  cord  which  is  tied  to  its  centre  and  passed 
out  of  a  small  perineal  wound  or  the  urethra  and  held  taut  externally 
by  clamping  it  tightly  against  a  piece  of  gauze.  At  the  end  of  twenty- 
four  hours  the  pad  may  be  carefully  removed.  The  bladder  can  be 
drained  by  a  suprapubic  tube  alone,  or,  better  still,  by  a  combined 
suprapubic  and  perineal  drainage. 

Orchideetomy ,  or  castration  (see  page  360),  for  the  relief  of  pros- 
tatic hypertrophy,  although  enthusiastically  brought  into  prominence 
of  late,  has  not  been  generally  endorsed  by  the  profession  at  large  as  a 
sound  surgical  procedure.  It  is  followed  in  some  cases  by  a  diminution 
of  the  congestion  and  swelling  of  the  glandular  elements  of  the  prostate, 
but  it  is  still  an  open  question  as  to  whether  there  is  a  true  and  perma- 
nent atrophy  or  shrinking  of  the  entire  gland  substance.  The  mortal- 
ity is  about  as  high  as  after  prostatectomy,  and  if  stone  is  present,  or  if 
portions  of  the  prostate  are  ulcerated  and  covered  with  calcareous  de- 
posits, the  patient  has  to  be  subjected  to  a  second  operation  for  its 
relief;  the  obstruction  to  urination  is  not  removed  immediately,  and 
therefore  the  inflamed  and  overworked  bladder,  sometimes  containing 
an  undetected  stone,  cannot  receive  the  immediate  benefit  of  free  drain- 
age which  is  so  essential  in  these  cases.  The  operation,  if  employed  at 
all,  should  only  be  done  in  those  cases  of  soft  boggy  prostate  and  never 
in  fibrous  and  myomatous  ones,  as  these  latter  can  only  be  benefited  by 
a  thorough  prostatectomy.  The  sexual  mutilation,  with  its  immediate 
and  remote  deleterious  and  even  fatal  effects  on  the  patient's  nervous 
system,  must  be  taken  into  serious  consideration. 

Vasectomy  has  been  suggested  and  practised  as  a  substitute  for 
castration.  It  is  at  best  an  experimental  procedure,  with  possibly  some 
therapeutic  value  in  certain  chronic  congested  conditions  of  the  prostate, 
but  not  in  true  hypertrophy.  The  operation  is  done  under  cocaine 
anaesthesia,  the  cord-like  vas  being  pinched  up  beneath  the  scrotal  tis- 
sues, which  are  divided  and  the  vas  hooked  out  through  the  little  wound ; 
two  ligatures  are  applied  about  an  inch  apart  and  the  included  portion 
excised. 

Ligation  of  the  internal  iliac  arteries  for  prostatic  hypertrophy  has 
been  performed,  and  is  merely  mentioned  here  to  be  most  emphatically 
condemned. 

21 


322 


AFFECTIONS   OF  THE  PROSTATE. 


The  Treatment  of  Retention  from  Hypertrophy  of  the  Prostate. 

— In  many  old  men  the  bulb  of  the  urethra  becomes  redundant  and  pouchy, 
and  its  relaxed  membrane  is  very  much  thrown  into  folds.  As  a  result 
of  this  flabby  condition,  when  the  tip  of  the  catheter  reaches  the  sinus 
of  the  bulb,  it  is  found  that  the  tonicity  of  the  tissues  is  so  lost  that 
there  is  nothing  left  of  a  firm  character  to  guide  its  further  progress. 
As  a  result,  the  end  may  impinge  on  the  sagging  lower  part  of  the  bulb, 
and  there  be  held  as  in  a  true  cul-de-sac.  In  general,  the  end  of  the 
instrument  catches  in  the  lower,  pouch-like  part  of  the  bulb,  and  it  is 
here  that  false  passages  are  usually  made,  in  which  case  the  instrument 
either  pierces  the  triangular  ligament  or  glides  under  it  and  makes  a 
pathological  channel  in  the  soft  tissues  beneath  the  membranous  urethra 
and  the  prostate. 

This  abnormal  anatomical  condition  of  the  bulbous  urethra  has  to  be 
met  with  appropriate  instruments.  What  is  needed  under  these  con- 
ditions is  an  instrument  of  sufficient  firmness  of  structure  to  make  its 
way  through  the  canal,  whose  end  points  slightly  upward,  and  which  at 
its  curve  shall  have  such  a  shoulder  that  if  it  sinks  down  to  the  lower 
wall  of  the  pouchy  bulb  its  tip  will  then  point  upward  and  strike  the 
orifice  of  the  bulbo-membranous  junction.  The  instruments  which  best 
fulfil  these  requirements  are  the  Mercier  coude  and  bi-coude  catheters. 
(See  Figs.  82  and  83.)  Whether  these  instruments  are  used  by  the  sur- 
geon or  by  the  patient,  it  is  always  very  necessary  that  there  shall  be 
some  reliable  guide  which  shall  point  to  the  side  of  the  instrument  which 
corresponds  to  its  convexity. 

Many  of  the  coude  catheters  on  sale  are  faulty  by  reason  of  the 
shortness  of  their  curved  portion,  which  should  be  fully  one  inch  long, 
and  in  accordance  with  the  curve  depicted  in  Figs.  82  and  83.     They 


Fig.  82. 


Coude  catheter. 
Fig.  83. 


Bi-coude  catheter. 


should  be  well  lubricated  and  slowly  passed  down  the  canal,  and  as  they 
traverses  the  bulbous  urethra  it  is  well  to  gently  guide  their  course  by 


TREATMENT  OF  RETENTION  FROM  HYPERTROPHY.         323 

steadying  the  parts  just  back  of  the  scrotum.  By  this  manoeuvre  the 
point  is  made  to  enter  the  bladder. 

In  enlargement  of  the  prostate,  in  the  main,  three  abnormal  condi- 
tions are  encountered  in  catheterization.  In  the  first  place,  the  urethral 
canal  may  be  much  elongated  by  the  progressive  growth  of  the  gland 
toward  and  in  the  bladder,  the  so-called  perineal  distance.  In  the 
second  place,  by  its  concentric  growth,  this  organ  so  contracts  the 
urethral  lumen  or  distorts  its  normal  straightness  of  direction  and  ren- 
ders it  sinnous,  that  much  impediment  to  urination  is  produced.  In  the 
third  place,  the  bar  or  the  valve-like  mass  at  the  vesical  orifice  may 
act  as  a  very  serious  obstacle  to  the  entrance  of  instruments  into  the 
bladder.  Now,  these  pathological  conditions  also  have  to  be  overcome 
by  means  of  appropriate  catheters. 

In  the  majority  of  cases  of  elongation  of  the  urethra,  with  a  corre- 
sponding greater  curve  of  the  canal,  the  bladder  can  readily  be  reached 
by  means  of  the  extra-curved  olivary  catheters  (see  Fig.  84),  called 

Fig.  84. 


Curved  olivary  catheters. 

prostatic  catheters.  These  instruments,  when  used  in  sizes  of  20  to  24 
French,  are  much  more  serviceable,  as  a  rule,  than  the  smaller  and 
larger  ones  are.  They  are  much  to  be  preferred  to  the  old-time  silver 
prostatic  catheter,  which  by  its  density  and  inflexibility  often  caused 
pain,  uneasiness,  and  inflammation.  The  long  curve  of  these  prostatic 
catheters  is  often  of  material  aid  in  traversing  a  pouchy,  bulbous 
urethra. 

In  some  cases,  soft  India-rubber  catheters  or  straight,  blunt-pointed, 
lisle-thread  catheters  will  readily  traverse  the  urethral  canal. 

It  may  be  necessary,  when  the  calibre  of  the  prostatic  urethra  is 
much  reduced  or  its  straightness  much  distorted,  to  use  these  catheters 
with  the  long  curve  or  the  straight  ones  in  sizes  smaller  than  20  French. 


324  AFFECTIONS  OF  THE  PROSTATE. 

When  the  catheters  already  spoken  of  cannot  be  obtained,  the  old- 
style  brick-red  English  catheter  may  be  used  if  at  hand.  It  is  well, 
if  it  is  a  straight  instrument,  to  soak  it  in  hot  water,  then  give  it  the 
necessary  curve,  which  may  be  rendered  sufficiently  permanent  by  im- 
mediate immersion  in  iced  water. 

In  cases  of  valvular  obstruction  or  of  a  bar  at  the  vesical  orifice, 
much  difficulty  may  be  met  in  reaching  the  bladder  cavity.  Sometimes 
the  tip  of  the  Mercier  catheter,  coude  and  bi-coude,  particularly  when 
smaller  than  20  French,  will  glide  over  the  obstruction  in  a  surprisingly 
prompt  manner.  Then  again  it  may  strike  against  it,  and  no  manoeuvre 
will  cause  it  to  traverse  it. 

In  many  cases  the  gum-elastic  prostatic  catheter  will,  by  the  forward 
tilting  or  bending  of  its  tips  or  forward  pressure,  glide  past  the  ob- 
struction upward  into  the  bladder.  In  these  obstinate  cases  it  may  be 
necessary  to  use  the  prostatic  guide,  which  will  steady  and  direct  a  soft- 
rubber  catheter.  Or  the  ordinary  wire  which  is  found  in  English 
catheters,  or  a  piece  of  ordinary  wire  ten  or  twelve  inches  long,  may  be 
curved  in  accordance  with  the  long  prostatic  urethra.  This  wire  is 
introduced  into  a  soft-rubber  catheter,  and  then  the  combined  instrument 
is  passed  until  it  reaches  the  bladder  or  comes  to  a  standstill  on  meeting 
the  obstruction.  Then  it  is  well  to  withdraw  the  wire  for  about  half  an 
inch,  and  again  push  forward,  when  the  flexible  end  may  clear  the 
obstruction.  If  this  procedure  fails,  the  surgeon  should  still  further 
pull  Out  the  wire  another  half  inch  and  then  try  to  pass  the  obstruction. 
In  case  of  final  failure,  the  condition  of  the  case  will  determine  in  the 
mind  of  the  surgeon  whether  it  is  necessary  to  resort  to  aspiration, 
suprapubic  puncture,  or  to  perform  suprapubic,  cystotomy. 

It  is  very  important  not  to  completely  empty  the  bladder  in  elderly 
or  old  men  who  are  suffering  from  retention  of  urine  due  to  prostatic 
hypertrophy  and  also  to  stricture  of  the  urethra.  (See  section  on  Re- 
tention of  Urine  Due  to  Stricture,  pp.  219  and  220.) 

TUBERCULOSIS. 

The  prostate  is  involved  in  the  majority  of  cases  of  tuberculosis  of 
the  genito-urinary  tract.  Its  development  may  be  primary  or  secondary 
to  infecting  foci  in  adjacent  or  remote  parts.  It  is  mostly  observed  at 
puberty  and  in  early  life. 

Tuberculosis  of  the  prostate  may  cause  azoospermatism  by  the  oblit- 
eration of  the  ejaculatory  ducts. 

The  course  of  tuberculosis  of  the  prostate  may  be  acute,  subacute, 
or  chronic. 

In  the  majority  of  cases  the  disease  begins  in  the  urethra,  but  it 


TUBERCULOSIS.  325 

is  also  found  in  the  substance  of  the  gland  and  on  its  periphery,  partic- 
ularly near  the  rectum. 

In  cases  of  urethral  involvement  the  symptoms  are  complained  of 
quite  early.  The  most  prominent  symptom  is  pain,  particularly  on 
urination,  which  may  be  very  urgent,  and  it  may  be  either  continuous 
or  intermittent.  Invasion  of  the  prostate  is  usually  followed  quite 
promptly  by  extension  to  the  bladder,  with  its  customary  group  of 
symptoms. 

In  cases  of  prostatic  tuberculosis  there  is  usually  a  more  or  less 
profuse  mucopurulent  discharge,  which  may  escape  spontaneously  or  on 
defecation.  When  the  tuberculous  nodules  are  seated  in  the  parenchyma 
of  the  prostate,  they  may  not  give  rise  to  pronounced  symptoms  for 
some  time.  This  is  particularly  the  case  when  the  course  is  very 
chronic.  When  the  tuberculous  nodules  are  seated  toward  the  periphery 
of  the  organ,  they  may  occasion  few,  if  any,  symptoms ;  but  when  they 
are  very  superficially  seated,  particularly  near  the  rectum,  they  may 
cause  pain  and  uneasiness  in  those  parts. 

On  rectal  examination  the  finger-tip  may  not  encounter  any  abnor- 
mality when  the  urethral  part  of  the  prostate  is  attacked.  When  the 
nodules  are  seated  in  the  parenchyma  of  the  organ  and  they  have 
become  quite  large,  or  when  several  have  coalesced  and  project  on  the 
surface,  their  presence  may  be  determined  by  palpation  with  the  finger 
in  the  rectum. 

The  diagnosis  of  prostatic  tuberculosis  may  be  made  by  examination 
of  the  morbid  secretion  or  of  the  urine.  But  in  many  cases  such 
examinations  fail  to  reveal  the  bacillus  tuberculosis  until  digital  pressure 
has  been  brought  to  bear  on  the  gland  and  on  the  urethral  canal. 

Treatment. — Tuberculosis  involving  the  urethral  canal  may  be 
benefited  by  prostatic  and  bladder  irrigations  of  warm  solutions  of 
bichloride  of  mercury  (1  :  1000  or  1  :  6000).  In  the  event  of  this 
treatment  causing  pain  and  urethral  irritation,  it  will  be  necessary  to 
discontinue  it.  In  some  cases  iodoform  and  sweet-oil  (10  per  cent.),  in 
the  form  of  injections,  have  seemed  of  benefit  in  cases  of  ulceration  of 
the  urethra. 

Tubercular  abscess  of  the  prostate  may  be  reached  by  a  crescentic 
incision  made  an  inch  in  front  of  the  anus  and  carried  down  between 
the  gland  and  the  rectum ;  they  are  then  incised  and  packed  with 
iodoform  gauze. 

Change  of  climate  (see  section  on  Tuberculosis  of  the  Testis,  p.  353) 
is  the  main  indication  in  these  cases,  which  are  usually  those  of  more 
or  less  extensive  distribution  of  the  tubercular  process. 


326  AFFECTIONS   OF  THE  PROSTATE. 

PROSTATIC   CALCULI. 

Prostatic  stones  originate  either  in  the  follicles  of  the  prostate  and 
increase  gradually  in  size  and  number,  or,  having  their  origin  in  the 
bladder,  leave  it,  and,  passing  into  the  prostatic  urethra,  become  more 
or  less  encysted  there,  and  by  slow  degrees  sink  into  the  gland  tissue. 
Their  surfaces  are  usually  faceted  and  highly  polished  from  the  constant 
friction  with  each  other.  They  are  made  up  principally  of  the  phos- 
phate of  lime. 

Symptoms. — In  some  cases  the  symptoms  are  very  mild  and  point 
to  slight  posterior  urethritis,  and  in  others  they  are  entirely  wanting. 
If,  however,  the  calculi  are  the  cause  of  prostatic  suppuration,  we  then 
have  the  typical  symptoms  pointing  to  this  condition. 

Treatment. — As  a  rule,  these  stones  should  be  removed  through 
a  perineal  incision,  although  there  are  some  cases  in  which  it  is  possible 
to  extricate  them  with  urethral  forceps. 


MALIGNANT   GROWTHS. 

Primary  carcinoma  and  sarcoma  of  the  prostate  are  extremely  rare, 
but  do  occur,  usually  at  and  after  middle  life,  carcinoma  being  the  more 
common  of  the  two. 

The  symptoms  at  first  are  practically  the  same  as  those  of  hyper- 
trophy, with  which  malignant  growths  are  sometimes  associated.  Very 
soon,  however,  the  pain  becomes  constant  and  intense,  radiating  into  the 
perineum,  abdomen,  penis,  and  thighs.  Urination  is  increased  in  fre- 
quency both  by  day  and  by  night,  until  in  a  short  time  the  patient  is  in  a 
state  of  constant  and  agonizing  tenesmus.  As  the  growth  increases  in 
size,  the  vesical  orifice  becomes  more  and  more  occluded  and  distorted, 
until  finally  complete  retention  is  added  to  the  patient's  deplorable  con- 
dition. Cystitis,  which  was  mild  at  first,  soon  becomes  more  marked 
on  account  of  the  decomposition  of  the  urine,  which  now  becomes 
alkaline  in  reaction.  Hemorrhages  are  often  profuse  and  frequent  and 
liable  to  occur  at  any  time  independent  of  urination.  The  patient  is 
greatly  reduced  thereby,  "*and  finally  dies  from  pain,  exhaustion,  and 
kidney  complications,  the  result  of  ascending  infection  and  urinary 
obstruction. 

Treatment. — If  the  malignant  nature  of  the  trouble  is  recognized 
at  an  early  enough  date  (which  is  rarely  done),  some  benefit  may  result 
from  a  removal  of  the  growth  through  a  suprapubic  incision  ;  later  on, 
however,  all  that  can  be  done  is  to  establish  suprapubic  drainage  and 
bladder  irrigation,  in  conjunction  with  the  intelligent  use  of  morphine 
and  the  regulation  of  the  patient's  general  condition. 


TRA  LIMA  TISMS.  327 

TRAUMATISMS. 

Wounds  of  the  prostate,  either  incised,  lacerated,  or  contused,  are 
exceedingly  rare,  on  account  of  the  protected  condition  of  the  gland. 
They  may  occur,  however,  in  the  course  of  surgical  operations  involving 
the  deep  perineal  region,  and  also  as  the  result  of  forcible  and  unskilful 
instrumentation  of  the  prostatic  urethra,  and  as  a  complication  of  crush- 
ing injuries  of  the  pelvis. 

Treatment. — Simple  incised  wounds  require  the  ordinary  surgical 
treatment  for  this  class  of  cases.  If,  however,  the  gland  and  deep 
urethra  are  extensively  lacerated,  the  bladder  should  be  drained  imme- 
diately by  the  perineal  route  to  prevent  urinary  extravasation,  hemor- 
rhage should  be  controlled,  and  the  parts  kept  scrupulously  clean,  as 
infection  in  this  region  is  apt  to  be  very  serious  on  account  of  the  rich 
plexus  of  prostatic  veins,  which  favor  the  absorption  of  poisonous 
material,  and  which  may  result  in  septicaemia  and  death. 


CHAPTER   XV. 

AFFECTIONS  OF    THE  TESTIS  AND  ITS  APPENDAGES  AND 

ENVELOPES.1 

HYDROCELE. 

By  the  term  hydrocele  we  understand  a  chronic  serous  effusion  into 
the  cavity  of  the  tunica  vaginalis  testis,  which  produces  more  or  less 
distention  of  the  scrotal  sac.  Hydrocele,  therefore,  must  not  be  con- 
founded with  the  acute  and  ephemeral  dropsy  of  the  vaginal  tunic 
which  occurs  in  acute  epididymitis,  and  which  is  called  acute  vaginalitis. 
Hydrocele  may  also  occur  in  cysts  of  the  testis  and  epididymis  and  in 
the  cord. 

For  clearness  of  description  we  may  divide  the  various  forms  of 
hydrocele  as  follows:  1,  hydrocele  of  the  tunica  vaginalis  testis;  2, 
hydrocele  of  the  cord ;  either  of  which  may  be  congenital  or  acquired. 

Congenital  Hydrocele  of  the  Tunica  Vaginalis  Testis. — Congeni- 
tal hydrocele  is  mostly  seen  in  young  subjects,  and  consists  anatomically 
in  the  communication  of  the  tunica  vaginalis  testis  with  the  peritoneal 
cavity  by  means  of  a  minute  duct  or  opening.  After  the  descent  of  the 
testis  from  the  abdominal  cavity  into  the  scrotum  there  has  been  failure 
in  the  obliteration  of  the  channel  of  communication  between  the  testic- 
ular serous  membrane  and  that  of  the  peritoneal  cavity.  When  this 
communication  exists  there  may  be  found  an  effusion  in  the  cavity  of 
the  tunica  vaginalis  which  produces  a  scrotal  tumor  when  the  patient 
stands  erect,  but  in  the  horizontal  position  the  tumor  is  effaced,  owing 
to  the  fluid  gravitating  back  into  the  peritoneal  cavity.  As  the  fluid 
thus  flows  backward  it  is  not  accompanied  by  a  gurgling  noise,  such  as 
is  produced  by  the  return  of  descended  intestine. 

Diagnosis. — The  tumor  in  congenital  hydrocele  is  smooth,  trans- 
parent, fluctuating,  translucent,  and  extends  from  the  bottom  of  the 
scrotum  into  the  inguinal  canal.  The  light  test  and  the  hypodermic 
syringe  will  give  much  aid  in  establishing  the  diagnosis.  Even  in  the 
upright  position  the  contents  of  the  tumor  may  be  by  pressure  forced 
into  the  peritoneal  cavity,  while  the  testicle  remains  in  the  scrotum. 
Then  with  the  tip  of  the  finger  over  the  inguinal  canal,  if  the  pressure 
is  slightly  removed  the  fluid  will  gravitate,  slowly  and  without  sensation 
to  the  finger,  back  into  the  scrotum.     An  intestine  in  thus  passing  down 

1  For  epididymitis  and  epididymo-orchitis  see  pp.  113  et  seq. 
328 


HYDROCELE.  329 

produces  decided  distention,  and  its  progress  can  be  distinctly  felt.  In 
the  horizontal  position  the  contents  of  congenital  hydrocele  pass  slowly 
on  by  pressure  into  the  abdominal  cavity  without  any  marked  sensation. 
On  the  other  hand,  the  reduction  of  a  hernia  is  attended  with  a  decided 
jump  or  impetus.  The  hydrocele  tumor  is  dull  on  percussion,  while  thai 
of  hernia  is  resonant. 

Treatment. — In  most  cases  of  congenital  hydrocele  a  firmly  applied 
truss  over  the  inguinal  canal  will  produce  obliteration  of  the  vaginal 
process,  after  which  the  fluid  in  the  tunica  vaginalis  will  be  absorbed  in 
a  short  time.  In  case  of  failure  of  this  procedure  the  sac  may  be  aspi- 
rated antiseptically  and  firm  pressure  may  again  be  applied. 

In  the  event  of  a  complicating  hernia  a  radical  operation  may  be 
performed  for  the  cure  of  both  conditions. 

Acquired  Hydrocele  of  the  Tunica  Vaginalis  Testis. — This  form 
of  hydrocele  is  most  commonly  seen  in  adults  and  in  persons  of  middle 
life  and  rather  exceptionally  in  adolescents.  It  therefore  occurs  in 
the  years  when  the  sexual  powers  are  at  their  best  and  the  testicular 
circulation  is  most  active,  and  when  individuals  are  most  commonly 
attacked  by  gonorrhoea  and  syphilis  and  liable  to  traumatisms  of  the 
genitals.  Simple  hydrocele  is,  as  a  rule,  unilateral  and  exceptionally 
bilateral.  As  usually  found,  the  scrotal  tumor  formed  by  the  hydrocele 
is  pear-shaped,  with  its  base  at  the  bottom  of  the  scrotum  and  its 
apex  directed  toward  the  external  abdominal  ring.  In  a  goodly  number 
of  cases  the  shape  of  the  tumor  is  distinctly  ovoid,  with  its  long 
axis  directed  vertically  or  perhaps  a  little  forward.  Less  commonly 
the  tumor  is  rather  roundish  in  shape.  The  size  of  the  tumor  varies 
with  the  amount  of  effusion,  which  may  be  several  ounces  or  even  pints. 
As  a  rule,  from  eight  to  sixteen  ounces  of  fluid  can  ordinarily  be  drawn 
from  cases  of  hydrocele. 

To  the  eye  the  scrotal  tumor  presents  a  quite  characteristic  picture. 
The  scrotal  wall  is  very  much  distended,  tense,  and  usually  much 
thinned,  and  the  scrotal  veins  are  very  distinct  and  enlarged.  By  palpa- 
tion a  very  firm  (see  Fig.  85),  resistant,  elastic  tumor  is  felt,  which  may 
give  a  sensation  of  slight  fluctuation.  Pressure  does  not  in  any  way 
render  the  tumor  smaller,  though  the  finger-tip  can  cause  a  depression 
for  a  moment. 

In  some  subjects,  particularly  fat  and  flabby  ones,  the  penis  is  drawn 
backward,  and  its  tegumentary  covering  is  largely  included  in  the  scrotal 
tumor,  which  hangs  quite  saliently  between  the  thighs. 

This  form  of  hydrocele  may  be  complicated  by  the  coexistence  of 
hernia.  When  the  latter  is  as  yet  non-adherent  to  the  hydrocele  the 
diagnosis  is  readily  made  by  the  impulse  on  coughing  and  the  resonance 
of  the  upper  tumor.     When  the  hernia  has  become  adherent  to  the 


330 


AFFECTIONS   OF  THE   TESTIS,   ETC. 


upper  end  of  the  hydrocele  much  care  is  necessary  in  making  a  diagnosis. 
In  cases  of  strangulation  of  the  hernial  sac  the  difficulty  in  making  the 
diagnosis  is  more  marked. 

Simple  hydrocele  is,  as  a  rule,  not  the  seat  of  pain,  and  it  can  be 
manipulated  with  impunity  except  on  its  posterior  and  upper  surface  or 
that  part  in  which  the  testis  is  situated.     Pressure  usually  causes  more 

Fig.  85. 


Hydrocele. 


or  less  discomfort,  and  it  is  here  that  patients  state  that  pain  exists, 
either  from  the  pressure  of  a  suspensory  or  from  over-exertion. 

The  onset  of  hydrocele  is  usually  very  slow  and  without  any  symp- 
toms. Its  further  course  is  also  slow  and  insidious,  so  that,  as  a  rule, 
the  tumor  has  reached  the  size  of  a  small  pear  before  its  presence  is 
recognized  by  the  patient. 

The  fluid  of  hydrocele  usually  has  a  straw  color  and  is  highly 
albuminous.  It  has  been  found  of  a  dark -brown  and  even  black  color 
from  admixture  with  blood.  It  sometimes  contains  a  small  quantity 
of  cholesterin,  and  in  some  few  instances  spermatozoa  have  been  found 
in  it.  In  some  cases  little  flakes  of  albumin  are  seen  floating  in  the 
fluid. 


HYDROCELE.  331 

Quite  exceptionally  the  fluid  of  hydrocele  looks  like  milk,  from  its 
admixture  with  lymph.  This  form,  termed  chylous  hydrocele,  is  ob- 
served in  southern  countries,  and  is  caused  by  the  filaria  sanguinis 
hominis  which  reaches  the  cavity  of  the  tunica  vaginalis  by  way  of 
the  lymphatics. 

Several  accidents  and  complications  may  occur  in  the  course  of 
hydrocele.  As  a  result  of  blows  or  other  traumatisms  blood  may  be 
effused  into  the  vaginal  cavity,  in  which  event  the  hydrocele  is  trans- 
formed into  hematocele. 

Inflammation  may  attack  the  walls  of  the  vaginal  sac,  which  is  the 
seat  of  hydrocele.  In  all  probability  this  is  the  result  of  traumatism. 
Purulent  inflammation  of  the  tunica  vaginalis  may  follow  tapping,  and 
there  can  be  no  doubt  that  the  trocar  in  these  cases  carries  the  pyogenic 
microbe  into  the  cavity.  In  this  inflammatory  process  the  walls  of  the 
tunica  vaginalis  may  become  very  much  thickened,  even  to  the  extent 
of  an  inch  or  more. 

Anomalous  Forms  of  Hydrocele. — Rather  infrequently  we  find  a 
scrotal  tumor,  due  to  hydrocele,  which  presents  an  uneven  surface  and  is 
more  compressible  in  some  parts  than  others.  This  condition  is  due  to 
exudative  or  adhesive  inflammation  of  the  tunica  vaginalis,  which  pro- 
duces bands  of  fibrous  tissue  which  divide  the  cavity  up  into  several  com- 
partments. Thus  is  produced  an  encysted  hydrocele,  which  may  not 
appear  translucent  when  the  light  test  is  applied. 

In  still  rarer  instances  we  find  that  owing  to  exudative  inflammation 
more  or  less  of  the  wall  of  the  tunica  vaginalis  is  thickened,  sometimes 
in  a  considerable  degree.  Upon  palpation  we  find  an  uneven  surface, 
and  a  marked  difference  is  experienced  between  the  thickened  plaque 
and  the  balance  of  the  unaltered  tunica  vaginalis.  Then,  again,  in  some 
cases  of  great  thickening  of  the  walls  there  are  areas  of  the  diameter  of 
half  an  inch  or  an  inch,  in  which  there  is  no  thickening  at  all,  and  on 
inspection  such  a  membrane  presents  an  appearance  similar  to  windows 
in  a  wall. 

Circumscribed  hydrocele  is  also  somewhat  rarely  found.  In  these 
cases  a  large  portion  of  the  two  layers  of  the  tunica  vaginalis  has  become 
adherent,  and  a  dropsy  has  occurred  in  a  limited  portion,  which  pro- 
duces a  swelling,  usually  round  or  oval,  which  is  attached  to  the  testis. 

Under  the  title  "  hydrocele  bilocularis,"  a  peculiar  and  rare  form 
of  the  affection  is  described.  (See  Fig.  86.)  In  this  form  the  hydrocele 
tumor  is  in  the  scrotum,  extends  up  the  inguinal  region  and  through  the 
rings  by  a  narrow  neck,  and  is  continuous  with  another  tumor  seated 
within  the  abdominal  cavity  and  underneath  the  parietal  peritoneum, 
and  entirely  independent  of  it.  In  this  form  of  hydrocele  the  vaginal 
process  of  the  peritoneum  has  become  obliterated  within  the  abdominal 


332 


AFFECTIONS   OF  THE   TESTIS,   ETC. 


cavity,  and  has  probably  not  undergone  obliteration  toward  the  testicle. 
"When  the  patient  stands  erect  the  scrotal  tumor  is  large  and  tense,  and 


Ftg.  86. 


Hydrocele  bilocularis. 

when,  in  the  horizontal  position  it  is  more  or  less  flaccid,  owing  to 
the  gravitation  of  the  fluid  into  the  abdominal  cavity.  The  dimensions 
of  this  form  of  hydrocele  are  sometimes  very  great.  In  one  case  the 
tumor  filled  part  of  the  abdominal  cavity  and  extended  up  to  the 
umbilicus  and  beyond  the  median  line. 

Another  rare  and  anomalous  form  is  called  "  diverticular  hydrocele." 
In  this  form  there  are  two  cavities,  the  one  around  the  testis,  and  the 
other  outside  of  that  and  communicating  with  it  by  means  of  a  small 
opening  or  neck.  This  hydrocele  begins  as  the  ordinary  form,  but, 
owing  to  some  cause,  perhaps  localized  thinning  of  the  sac-wall,  a  slight 
bulging  occurs,  and  soon  a  diverticulum  is  formed.  This  second  cavity 
goes  on  increasing  until  it  becomes  larger  than  the  original  sac.  The 
orifice  of  communication  in  these  cases  is  about  large  enough  to  admit 
the  tip  of  the  forefinger,  and  by  its  firm  structure  it  remains  permanent. 
The  translucency  is  marked  in  this  form  of  hydrocele,  owing  to  the 
extreme  thinness  of  the  walls  of  the  diverticulum. 

Diagnosis. — The  diagnosis  of  hydrocele  is  usually  quite  easy.  Its 
slow  development  without  symptoms,  its  beginning  at  the  bottom  of 
the  scrotum,  its  pyriform  or  oval  shape,  are  presumptive  symptoms,  of 
much  importance.     The  crucial  test  of  hydrocele,  however,  is  its  trans- 


HYDROCELE.  333 

lucency,  and  this  may  be  determined  by  what  is  known  as  the  "  light 
test."  The  simplest  application  of  this  test  is  as  follows :  In  strong 
sunlight  the  patient  is  made  to  stand  before  the  surgeon,  who  sits  at 
his  side  :  he  then  shades  the  convexity  of  the  tumor  with  the  outer  side 
of  his  hand,  and  examines  the  organ.  In  cases  where  the  scrotal  wall 
and  the  tunica  vaginalis  are  thin  and  their  fluid  transparent,  translu- 
cency  can  readily  be  made  out.  In  the  absence  of  sunlight  a  candle, 
a  gas-light,  or  the  electric  light  may  be  used.  The  light  is  placed  on 
the  opposite  side  of  the  scrotum,  and  the  surgeon  examines  the  part 
either  by  means  of  a  cylinder  of  paper  or  by  shading  his  eye  with  the 
hand.  Distinct  translucency  is  seen  in  the  anterior  portion  of  the 
tumor,  while  posteriorly  the  opaque  body  of  the  testis  may  be 
detected.  This  body,  when  thus  inspected,  usually  looks  rather  smaller 
than  one  expects  to  find  it.  In  somewhat  rare  cases  we  find  the  testis 
situated  anteriorly  and  at  the  upper  part  of  the  tumor,  the  tunica  vag- 
inalis being  placed  posteriorly.  Quite  exceptionally  the  testis  is  at  the 
bottom  of  the  tumor. 

In  many  cases  it  is  utterly  impossible  to  clearly  define  the  outlines 
of  the  testis  by  palpation.  Its  position,  however,  may  then  be  ascer- 
tained by  pressure,  which,  when  made  on  the  organ,  causes  pain  or  dis- 
comfort. When  the  testis  can  be  made  out,  it  is  often  impossible  to 
define  the  outlines  of  the  epididymis,  the  reason  being  that  with  the 
distention  of  the  tunica  vaginalis  the  parts  are  so  spread  out  that  the 
epididymis  lies  flat  on  the  tumor  and  presents  very  little  if  any  salience. 
After  the  withdrawal  of  the  fluid  the  testis  and  epididymis  regain  their 
normal  relations. 

In  old  hydrocele  such  is  the  thickness  of  the  sac  that  the  trans- 
lucency is  quite  dim.  In  very  dense,  thick  sacs  there  is  no  translucency 
whatever. 

The  points  in  diagnosis  between  hydrocele  and  hernia  are  as  follows  : 
In  hydrocele  the  tumor  presents  dulness  on  percussion ;  there  is  no 
impetus  on  coughing  and  no  change  in  the  tumor  when  the  patient  is 
in  the  horizontal  position.  In  hernia,  particularly  incarcerated,  the 
tumor  comes  usually  suddenly  from  above,  where  it  is  largest,  and  is 
doughy,  and,  as  a  rule,  resonant,  on  percussion. 

Two  forms  of  testicular  diseases  may  be  mistaken  for  hydrocele, 
namely,  syphilitic  orchitis  and  cystic  sarcoma. 

In  syphilitic  orchitis  the  enlargement  occurs  slowly  in  the  whole 
extent  of  the  testis  and  epididymis  and  not  at  the  bottom  of  the 
scrotum.  As  the  tumor  forms  it  becomes  hard  and  heavy  and  may  be 
accompanied  by  slight  hydrocele  of  the  tunica  vaginalis.  In  syphilitic 
orchitis  there  is  usually  a  history  of  infection  or  of  some  other  specific 
lesion  or  lesions.     In  this  form  of  tumor  there  is  never  translucency. 


334  AFFECTIONS  OF  THE   TESTIS,   ETC. 

Cystic  sarcoma,  like  hydrocele,  is  seen  mostly  in  young  men.  It 
begins  slowly  by  general  painless  enlargement  of  the  testis  and  may 
remain  as  a  small  tumor  for  some  time.  It  is  very  liable  to  undergo 
exacerbations  of  growth  and  to  form  a  very  large  tumor  in  a  few 
months.  The  main  diagnostic  points  are  the  rapid  development  and 
the  formation  of  a  dense  heavy  scrotal  tumor  in  which  translucency 
cannot  be  detected. 

Chronic  hsematocele  of  the  tunica  vaginalis  may  be  mistaken  for 
hydrocele,  but  a  history  of  the  case  and  the  absence  of  translucency  in 
tumor  will  generally  be  of  aid  in  forming  a  diagnosis. 

Causes  of  Hydrocele. — The  essential  cause  of  hydrocele  is  chronic 
inflammation  in  the  epididymis  or  testis  and  perhaps  in  the  spermatic 
cord.  Some  cases  of  hydrocele  are  the  direct  but  chronic  outcome  of 
the  acute  vaginalitis  which  occurred  in  gonorrhoeal  epididymites  or 
epididymo-orchitis.  Chronic  gonorrhoeal  epididymitis  with  cell  pro- 
liferation in  the  head  of  the  epididymis  pressing  on  the  efferent  vessels 
of  this  part  not  uncommonly  gives  rise  to  chronic  hydrocele.  All 
chronic  inflammations  of  the  testis  (particularly  when  there  is  coexistent 
epididymal  affection),  whether  due  to  gonorrhoea,  syphilis,  tuberculosis, 
or  cancer,  may  be  accompanied  by  a  chronic  effusion  into  the  cavity  of 
the  tunica  vaginalis. 

Hydrocele  has  been  known  to  follow  varicocele,  and  it  is  thought  by 
some  that  the  latter  condition  is  sometimes  the  determining  cause  of  the 
former. 

Hydrocele  may  occur  as  a  complication  of  general  dropsy,  but  it  is 
very  probable  that  in  that  event  there  was  some  antecedent  testicular 
injury  or  disturbance. 

Traumatism  undoubtedly  is  a  frequent  cause  of  hydrocele.  It  is  so 
common  to  find,  particularly  on  the  visceral  layer  of  the  tunica  vaginalis, 
patches  showing  antecedent  hemorrhage,  or  of  chronic  inflammation  and 
cicatrization,  that  in  the  absence  of  a  history  of  gonorrhoea  no  other  cause 
than  injury  can  be  assigned. 

Hydrocele  undoubtedly  results  in  every  case  from  some  definite  dis- 
turbance of  the  equilibrium  of  the  circulation,  the  origin  of  which  is  not 
always  apparent.  It  is  safe  to  say  that  the  disturbance  in  the  circula- 
tion exists  somewhere  in  the  testicle  or  the  cord. 

Inguinal  hernia,  particularly  when  voluminous,  has  been  thought  to 
be  a  cause  of  hydrocele. 

Pathological  Anatomy. —  In  the  course  of  hydrocele,  there  is,  as  a 
rule,  serous  effusion,  and  besides  this  there  may  be  fibrinous  exudation 
and  parenchymatous  thickening.  In  some  recent  cases  of  hydrocele  no 
thickening  of  the  serous  membrane  can  be  discovered,  and  in  many  it  is 
even  thinner  than  normal,  and  the  most  noticeable  feature  in  either  case 


HYDROCELE.  335 

is  more  or  less  hyperemia,  the  vessels  being  numerous  and  prominent. 
In  further  advanced  cases  the  membrane  is  decidedly  thickened,  of  a 
pearly-white  color,  and  streaked  by  numerous  vessels. 

In  very  old  hydroceles  a  thickening  of  one  or  two  lines,  and  even 
to  the  extent  of  an  inch  or  more,  may  be  found.  In  many  cases  of  thick- 
ening the  serous  surface  is  still  smooth  and  glossy.  Evidences  of  fibrin- 
ous exudation,  local  or  general,  are  not  uncommonly  observed.  Thus, 
the  surface  may  be  simply  a  little  rough  and  more  than  ordinarily  opaque, 
or  it  may  be  covered  with  little  tufts  or  patches  of  false  membrane.  In 
fact,  all  the  features  of  exudative  and  adhesive  inflammation  of  serous 
membranes  may  be  found  in  the  tunica  vaginalis.  The  endothelium  is 
then  thrown  off,  and  the  surface  becomes  covered  with  a  membrane  of 
plastic  lymph  looking  sometimes  like  velvet,  again  like  lace,  and  some- 
times a  general  nutmeg-grater  roughness.  As  a  result  of  this  adhesive 
inflammation  the  visceral  and  parietal  layers  may  be  glued  together  in 
patches  of  greater  or  less  size. 

In  rare  instances  the  hydrocele  sac  becomes  calcified,  in  which  event 
there  is  no  translucency  and  the  testicular  tumor  becomes  hard  and 
somewhat  nodulated. 

Very  exceptionally  free  bodies  are  found  in  the  cavity  of  the  tunica 
vaginalis  testis.  These  are  small  masses  of  fibrinous  or  cartilaginous 
material,  perhaps  coated  with  calcareous  matter.  It  is  supposed  that 
they  are  excrescences  which  have  developed  near  the  epididymis  or  on 
the  surface  of  the  testicle  and  have  become  detached.  They  sometimes 
give  rise  to  pain  in  the  parts. 

Treatment. — The  treatment  of  hydrocele  may  either  be  palliative 
or  radical ;  by  the  former  we  merely  remove  the  fluid  temporarily,  by 
the  latter  we  hope  by  means  of  caustic  injections  or  resections  to  pro- 
duce obliteration  of  the  cavity  of  the  tunica  vaginalis. 

For  various  reasons  many  patients  prefer  to  have  their  hydroceles 
tapped  from  time  to  time,  rather  than  undergo  any  operation  more 
radical. 

Tapping. — This  is  a  simple  operation.  The  patient  stands  before 
the  surgeon  and  the  position  of  the  testes  is  clearly  made  out  by 
him  ;  in  general,  it  being  upward  and  backward.  The  scrotum  is 
rendered  surgically  clean.  It  is  then  grasped  by  the  left  hand  of  the 
surgeon  at  its  posterior  portion  and  enough  pressure  is  exerted  to 
render  the  anterior  wall  very  tense.  The  asepticized  trocar  of  small 
calibre  is  held  in  the  surgeon's  right  hand,  and  he  allows  about  an 
inch  and  a  half  of  its  canula  to  protrude  between  the  thumb  and  fore- 
finger. He  then  selects  the  middle  and  most  prominent  part  of  the 
scrotal  tumor,  at  a  spot  where  there  are  no  perceptible  veins,  as  the  point 
of  puncture,  and  into  this  he  gently  but  firmly  pushes  the  canula  in  a 


336  AFFECTIONS  OF  THE  TESTIS,  ETC. 

slightly  upward  and  backward  direction.  The  canula  being  well  in  the 
cavity  of  the  tunica  vaginalis,  the  trocar  is  withdrawn  and  the  fluid  is 
allowed  to  flow  out.  By  this  procedure  the  trocar  does  not  hitch  or 
halt  in  the  wall  of  the  hydrocele,  nor  is  the  testicle  wounded.  After 
the  operation  the  little  wound  may  be  covered  with  a  piece  of  sterilized 
gauze.  In  some  cases  it  is  necessary  to  repeat  this  operation  in  from 
three  to  six  months,  in  others  the  interval  of  refilling  of  the  hydrocele 
sac  is  longer. 

Injection  Treatment. — If  we  aim  at  a  radical  cure  and  a  cutting 
operation  is  out  of  the  question,  we  may  inject  either  tincture  of  iodine 
or  carbolic  acid  into  the  sac,  with  the  purpose  of  producing  such  marked 
exudative  inflammation  that  the  walls  of  the  tunica  vaginalis  will  be- 
come adherent  to  one  another.  The  first  step  in  this  operation  is  the 
withdrawal  of  the  hydrocele  fluid  by  tapping  [vide  supra).  The  canula 
is  retained  in  the  sac  and  the  injection  is  made  by  means  of  a  small 
india-rubber  or  all-glass  syringe,  whose  nozzle  has  been  prepared  to  fit 
accurately  into  its  mouth.  If  tincture  of  iodine  is  employed,  two  to  four 
drachms  may  be  slowly  thrown  into  the  vaginal  cavity.  If  carbolic 
acid  is  used,  from  60  to  90  drops  of  the  recently  deliquesced  acid  may 
be  injected.  After  the  injection,  the  canula  still  being  in  situ,  it  is 
necessary  to  carefully  knead  and  manipulate  with  the  fingers  the  parts 
operated  upon,  in  order  that  the  caustic  fluid  shall  come  in  contact 
with  every  portion  of  the  tunica  vaginalis  testis.  This  having  been 
accomplished,  any  remaining  fluid  in  the  vaginal  cavity  should  be 
allowed  to  escape  through  the  canula,  which  then  may  be  removed. 

The  following  procedure  has  been  proposed  with  the  idea  of  pre- 
venting the  pain  of  the  irritant  injection  :  The  tapping  is  performed, 
and  when  about  one-half  of  the  hydrocele  fluid  has  escaped,  one  drachm 
of  an  8  per  cent,  muriate  of  cocaine  solution  is  injected.  This  by 
manipulation  is  made  to  diffuse  itself  with  the  hydrocele  fluid,  and  five 
or  ten  minutes  are  allowed  to  elapse  before  the  latter  is  wholly  drawn 
off.     Then  the  caustic  injection  may  be  made. 

This  operation  should  be  done  at  the  patient's  home  or  at  a  hospital. 
The  immediate  result  may  be  slight  or  very  severe  reaction  in  the  shape 
of  heat,  swelling,  and  more  or  less  pain.  The  patient  must  be  kept  in 
the  recumbent  position,  and  cooling  lotions  applied  to  the  scrotum. 
The  patient  is  about  usually  in  a  few  days,  but  he  may  be  confined  at 
home  for  a  week  or  longer,  during  which  time  he  suffers  much  dis- 
comfort. 

In  justice  to  the  patient,  it  is  well  to  make  him  clearly  understand 
that  this  injection  treatment  is  not  successful  in  every  case.  This  may 
be  said  in  spite  of  the  contention  of  some  enthusiasts  who  claim  uniform 
and  invariable  cure.      Failures  after  carbolic  acid  are  less  frequent  than 


HYDROCELE.  337 

after  tincture  of  iodine,  but  they  -will  follow  in  a  goodly  proportion  of 
cases  no  matter  how  carefully  and  thoroughly  the  injection  has  been 
made,  nor  how  skilful  is  the  operator. 

The  few  successful  cases  after  this  operation  are  those  of  recent 
small  hydroceles,  in  which  the  walls  of  the  sac  are  very  thin  ;  when  the 
latter  are  thick  and  infiltrated,  a  failure  can  be  confidently  predicted. 

Volkmann's  Operation. — Incision  and  Drainage. — This  oper- 
ation is  one  of  much  utility  and  is  largely  employed,  its  aim  being  to 
produce  a  radical  cure. 

It  is  performed  as  follows :  The  patient  is  anaesthetized  and  the  oper- 
ative field  is  rendered  aseptic.  A  vertical  incision,  two  or  three  inches 
in  length,  is  made  in  the  middle  of  the  tumor  toward  its  lower  part. 
The  dissection  is  slowly  made  down  to  the  surface  of  the  hydrocele,  all 
vessels  being  clamped  and  ligated  as  the  operation  proceeds.  The  fluid 
is  then  let  out  by  a  quick  stab  carefully  made  into  the  vaginal  tunic, 
and  the  full  incision  is  then  completed  with  blunt  scissors.  The  cut 
edges  of  the  vaginal  tunic  are  then  sutured  with  gut  to  the  correspond- 
ing incised  edges  of  the  scrotal  wound.  The  visceral  and  parietal  layers 
of  the  tunica  vaginalis  are  carefully  swabbed  with  pure  deliquesced 
carbolic  acid.  The  parts  are  brought  together  after  a  long  drainage- 
tube  has  been  inserted,  or  the  wound  may  be  lightly  packed  with  iodo- 
form gauze.  Over  the  whole,  plenty  of  sterilized  cotton  and  gauze  is 
placed  and  a  T-bandage  is  firmly  applied.  Renewal  of  the  dressing  is 
necessary  every  day  or  two,  great  care  being  exercised  as  to  antisepsis. 
If  a  drainage-tube  has  been  used,  it  will  be  necessary  to  shorten  it  as 
the  scrotal  tissues  become  contracted. 

In  general  the  operation  is  followed  by  a  radical  cure,  but  in  a  few 
cases  recurrence  of  the  hydrocele  has  been  observed. 

This  operation  may  be  performed  under  cocaine  anaesthesia  by  using 
deep  injections  all  along  the  line  of  incision. 

Von  Bergmann's  Operation. — Resection  of  the  Sac. — The 
most  satisfactory  radical  operation  for  hydrocele  is  performed  in  the 
following  manner  :  The  patient  is  anaesthetized  and  the  operative  field 
is  prepared  in  the  usual  manner.  A  vertical  incision  is  made  over  the 
anterior  surface  of  the  tumor  and  is  carried  well  down  until  the  sac 
proper  is  thoroughly  exposed.  The  hydrocele  is  then  shelled  out  by 
means  of  the  fingers  from  the  ambient  scrotal  tissues,  with  the  exception 
of  its  posterior  attachments.  The  sac  is  then  freely  incised  and  the 
parietal  layer  of  the  tunica  vaginalis  is  completely  resected  up  to  within 
half  an  inch  from  the  testis  and  epididymis.  During  the  operation  all 
bleeding  points  are  to  be  clamped  and  ligated.  The  edges  of  the  wound 
are  then  carefully  approximated  and  sutured.     If  so  desired,  the  wound 


338  AFFECTIONS   OF  THE  TESTIS,   ETC. 

may  be  drained  at  its  lower  angle.  The  ordinary  antiseptic  dressings 
are  applied  and  held  in  place  by  a  T-bandage. 

This  method  of  shelling  out  the  sac  en  masse  prevents  in  a  marked 
degree  the  free  hemorrhage  which  always  accompanies  resection  of  the 
sac  after  the  fluid  has  been  evacuated. 

Refilling  of  the  hydrocele  does  not  follow  this  operation.  When  the 
parts  have  completely  healed,  the  testicle  is  found  to  hang  free  in  the 
ambient  connective  tissue  of  the  scrotum. 

Inversion  of  the  Tunica  Vaginalis  Testis  for  Hydrocele. — 
This  operation  has  of  late  found  favor  in  the  United  States  and  abroad, 
and  is  said  to  produce  good  results.  It  is  known  as  Winkelmann's  opera- 
tion, which  was  originally  devised  by  Doyen  and  Jaboulay,  of  Lyons, 
France.  It  is  to  be  performed  in  the  following  manner :  The  parts  are 
first  rendered  surgically  clean.  The  usual  incision  is  made  through  the 
scrotal  tissues  and  into  the  hydrocele.  After  the  hydrocele  fluid  has 
escaped  the  testicle  is  drawn  completely  out,  so  that  the  entire  tunica 
vaginalis  is  turned  inside  out.  The  incision  in  the  tunica  then  comes  in 
relation  with  the  insertion  of  the  spermatic  cord  into  the  testicle,  which 
incision  may  be  shortened  by  a  suture  or  two  so  that  the  testicle  cannot 
return  through  the  opening  of  the  tunica.  The  tunica  and  testicle  are 
replaced  in  the  scrotum,  with  the  result  that  the  entire  serous  surface  of 
the  tunica  vaginalis  proper  faces  outward  toward  the  loose  connective  tissue 
of  the  tunica  vaginalis,  with  which  it  may  soon  become  fused,  the 
testicle  lying  outside  the  tunica,  between  the  tunica  and  the  scrotal  wall. 
The  parts  are  sutured  and  treated  in  the  usual  manner^  It  is  said  that 
no  unpleasant  sequelae  follow  this  procedure. 

Encysted  Hydrocele  of  the  Epididymis  and  Testis. — There  are 
two  varieties  of  this  kind  of  hydrocele — one  arising  from  the  epididymis, 
and  called  by  some  "spermatocele,"  and  the  other  from  the  body  of  the 
testicle.  Either  variety  may  be  complicated  by  hydrocele  of  the  tunica 
vaginalis.  These  cysts  are  of  two  kinds — subserous  and  parenchymatous, 
or  small  and  large. 

The  covering  or  walls  of  the  subserous  cysts,  which  are  superficial, 
are  composed  simply  of  stretched  serous  membrane,  while  the  walls  of 
the  parenchymatous,  which  are  developed  in  the  connective  tissue,  are 
dense  and  firm.  The  subserous  cysts  are  usually  multiple,  and  are 
found  above  and  around  the  head  of  the  epididymis  ;  they  are  generally 
about  the  size  of  a  pea.  They  contain  a  clear,  pellucid  fluid,  which  is 
sometimes  of  a  milky  hue.  These  cysts  sometimes  become  fused 
and  form  a  single  large  one  having  a  pedunculated  base ;  they  never 
have  any  connection  with  the  efferent  tubes  of  the  testis,  and  rarely 
cause  uneasiness.  Occasionally,  when  old,  these  cysts  have  such  thick 
walls  as  to  be  mistaken  for  solid  tumors. 


HYDROCELE  OF  THE  SPERMATIC  CORD.  339 

The  large  cysts  are  usually  found  below  the  head  of  the  epididymis, 
close  to  the  anterior  extremity  of  its  lower  border.  They  are  formed 
in  the  connective  tissue  beneath  the  investing  membrane  of  the  epididy- 
mis and  in  close  contact  with  the  efferent  tubes.  These  have  received 
the  name  of  encysted  hydrocele  of  the  epididymis.  The  epididymis  is 
flattened  and  displaced  laterally,  while  the  testis  is  found  below,  in 
front  of,  or  at  the  side  of  the  cyst,  very  rarely  behind  it.  The  contained 
fluid  is  slightly  albuminous,  colorless,  and  sometimes  contains  sperma- 
tozoa and  molecules  of  fibrin. 

Cysts  springing  only  from  the  body  of  the  testis  are  quite  rare. 
They  are  due  to  effusion  between  the  tunica  albuginea  and  the  deeper 
layer  of  the  tunica  vaginalis.  Occasionally  a  cyst  is  seated  partly  upon 
the  epididymis  and  partly  upon  the  testicle.  The  walls  of  a  recent 
cyst  are  thin  and  translucent ;  as  the  cyst  grows  older  its  walls  become 
thick,  dense,  and  fibrous,  sometimes  even  containing  spiculas  of  bone 
and  becoming  lined  with  false  membrane.  The  fluid  is  at  first  pellucid, 
but  after  a  time  it  assumes  a  yellow  or  even  a  deep-brown  color. 

Diagnosis.— Encysted  hydrocele  of  the  epididymis  is  usually  recog- 
nized from  the  position  and  number  of  the  cysts.  In  cases  of  doubt, 
especially  when  the  cysts  are  hard  and  firm,  the  introduction  of  a  hypo- 
dermic needle  will  determine  whether  they  contain  fluid.  The  difference 
in  shape  between  these  large  cysts  and  hydrocele  of  the  tunica  vaginalis 
is  an  important  point,  while  the  position  of  the  testicle  at  the  bottom 
of  the  tumor  confirms  the  suspicion  of  large  encysted  hydrocele. 

In  some  cases,  however,  on  account  of  abnormalities  in  position,  a 
positive  diagnosis  can  only  be  made  by  drawing  off  some  of  the  fluid, 
which  is  generally  pellucid  or  milky  rather  than  straw  colored.  Trans- 
lucency  and  fluctuation  are  additional  points  in  the  diagnosis. 

Treatment  of  Encysted  Hydrocele. — The  small  encysted  hydrocele 
seldom  requires  any  attention  unless  it  tends  to  increase  in  size  or  become 
painful,  when  the  fluid  may  be  drawn  off  with  a  hypodermic  needle. 
This  operation  sometimes  gives  permanent  relief,  but  may  need  to  b6 
repeated.  Large  cysts  should  be  tapped  separately  and  injected  with 
tincture  of  iodine.  Sometimes  the  tapping  and  injection  of  a  single 
cyst  cause  subsidence  of  all  the  rest.  Volkmann's  operation  may  be 
employed  after  failure  of  tapping.     [Vide  supra.) 

Hydrocele  of  the  Spermatic  Cord. — There  are  two  varieties  of 
hydrocele  of  the  cord,  the  diffused  and  the  encysted. 

The  diffused  form  is  merely  a  serous  infiltration  into  the  loose  and 
abundant  connective  tissue  of  the  cord.  The  scrotal  sac  is  free  from  all 
appearances  of  disease,  except  that  when  the  skin  is  not  congested  it 
seems  rather  fuller,  and  hangs  rather  lower  on  the  affected  side  than  on 
the  other,  and,   if  suspended  lightly   in  the  palm  of  the  hand,  feels 


340  AFFECTIONS  OF  THE  TESTIS,  ETC. 

heavier ;  the  testicle  with  its  epididymis  is  to  be  felt  perfectly  distinct 
below  this  fulness,  neither  enlarged  nor  in  any  manner  altered  from  its 
natural  state ;  the  spermatic  cord  is  considerably  larger  than  it  ought  to 
be,  and  feels  like  a  varix  or  like  an  omental  hernia,  according  to  the 
different  sizes  of  the  tumor ;  it  has  a  pyramidal  kind  of  form,  broader 


Fig.  87. 


Fig. 


Diffuse  hydrocele  of  the  cord.  Encysted  hydrocele  of  the  cord 


at  the  bottom  than  at  the  top  ;  by  gentle  and  continued  pressure  it  seems 
gradually  to  recede  or  go  up,  but  drops  down  again  immediately  upon 
removing  the  pressure,  and  that  as  freely  in  a  supine  as  in  an  erect 


HYDROCELE  OF  THE  SPERMATIC  CORD.  341 

posture.  It  is  attended  with  a  very  small  degree  of  pain  or  uneasiness, 
which  uneasiness  is  not  felt  where  the  tumefaction  is,  but  in  the  loins. 
If  the  extravasation  be  confined  to  the  spermatic  cord,  the  opening  in 
the  tendon  of  the  abdominal  muscle  is  not  at  all  dilated,  and  the  process 
passing  through  it  may  be  very  distinctly  felt ;  but  if  the  connective 
tissue  which  invests  the  spermatic  vessels  within  the  abdomen  be  affected, 
the  tendinous  aperture  is  enlarged,  and  the  increased  size  of  the  distended 
membrane  passing  through  it  produces  to  the  touch  a  sensation  not  very 
unlike  that  of  an  omental  rupture.     (See  Fig.  87.) 

This  form  of  hydrocele  may  be  mistaken  for  a  hernia.  The  latter 
often  passes  into  the  abdomen  when  the  patient  lies  down,  while  the 
former  is  but  slightly  if  at  all  displaced.  The  swelling  of  hydrocele  is 
firmer,  though  doughy,  and  fluctuating ;  a  hernia,  moreover,  unless  it 
be  omental,  is  resonant  on  percussion.  The  impulse  on  coughing  in 
hernia  is  quite  different  from  the  very  slight  downward  movement  of 
the  enlarged  cord  in  hydrocele.  In  hernia  the  cord  can  always  be 
traced  in  normal  size  from  the  testis  to  the  ring. 

The  treatment  consists  in  making  small  punctures  at  the  most 
dependent  part  of  the  tumor,  and  in  subsequently  maintaining  pressure- 
In  very  chronic  cases  large  blisters  should  be  employed. 

Encysted  hydrocele  of  the  cord  occurs  most  commonly  in  infants.  It 
forms  slowly  and  without  pain,  and  may  reach  the  size  of  an  egg  before 
being  seen  by  the  surgeon.  It  is  distinctly  circumscribed,  round  or 
oval,  translucent,  firmly  attached  to  the  spermatic  cord,  movable  upon 
firm  traction,  and  not  involving  the  overlying  skin.  It  is  firm  in  con- 
sistence and  but  slightly  fluctuating.     (See  Figs.  87  and  88.) 

There  is  seldom  more  than  one  tumor,  but  we  sometimes  find  a  series 
of  tumors  extending  from  the  testis  to  the  external  abdominal  ring. 
When  occurring  in  infancy  the  lesion  may  result  from  imprisonment  of 
a  congenital  hydrocele ;  in  adults,  however,  it  originates  in  the  same 
manner  as  do  the  hydroceles  of  the  epididymis.  The  cyst- wall  is  usually 
thin  and  fibrous,  but  in  chronic  cases  it  becomes  very  thick  and  tough. 
The  fluid  contents  of  the  cyst  are  colorless,  like  water,  or  viscid  and 
mucoid,  and  sometimes  spermatozoa  are  found  in  it. 

These  cysts  may  be  seated  at  any  part  of  the  cord ;  those  of  the 
epididymis  are  sometimes  wrongly  considered  cysts  of  the  cord.  When 
the  latter  are  seated  near  the  external  abdominal  ring  the  diagnosis  may 
be  very  difficult,  otherwise  it  is  generally  easy.  The  character  and 
situation  of  the  tumor  and  its  mobility  with  the  cord  and  testis  are 
usually  distinctive.  The  danger  of  mistaking  hernia  for  encysted 
hydrocele  may  be  avoided  by  observing  the  uniform  size  of  the  latter, 
its  circumscribed  condition,  its  translucency,  and  the  absence  of  impulse 
on  coughing  and  of  the  gurgling  sensation.     (See  Fig.  89.) 


342 


AFFECTIONS  OF  THE  TESTIS,   ETC. 


Treatment. — In  children  this  affection  usually  disappears  spontane- 
ously. The  process  of  absorption  may  be  hastened,  if  desirable,  by 
counter-irritation  with  tincture  of  iodine.  Withdrawal  of  the  fluid  and 
subsequent  pressure  sometimes  produce  a  perfect  cure.     In  very  obsti- 


Fig. 


Encysted  hydrocele  of  the  cord. 

nate  cases  injection  of  the  tincture  of  iodine  or  carbolic  acid  may  be 
resorted  to.  A  modified  "Volkmann's  operation  may  be  performed, 
particularly  in  cases  of  multilocnlar  cysts. 

Hydrocele  of  a  Hernial  Sac. — In  some  very  rare  cases  of  inguinal 
or  scrotal  hernia,  the  sac  becomes  obliterated  and  shut  off  from  the 
peritoneal  cavity.  This  closed  sac  may  contain  fluid  and  a  portion  of 
gut  or  omentum,  and  the  condition  is  termed  hydrocele  of  a  hernial 


HEMATOCELE.  343 

sac.  This  tumor  may  or  may  not  be  translucent,  and  may  be  the  seat 
of  fluctuation.  It  may  be  necessary  to  make  an  exploratory  incision  in 
order  to  establish  the  diagnosis. 

Treatment. — The  sac  must  be  excised  and  a  radical  operation  for 
hernia  performed. 

HEMATOCELE. 

Hematocele  is  an  acute  or  chronic  effusion  of  blood  into  the  cavity 
of  the  tunica  vaginalis  testis,  into  the  testis  itself,  the  epididymis,  or 
the  cord,  or  into  all  these  structures  combined. 

Hematocele  of  the  Tunica  Vaginalis  Testis. — This  affection  occurs 
in  an  acute  and  chronic  form. 

Acute  Form. — This  form  is  usually  of  traumatic  origin.  The  effu- 
sion of  blood  may  take  place  into  a  vaginal  cavity  previously  the  seat 
of  hydrocele  or  into  a  perfectly  healthy  one. 

The  exciting  causes  of  acute  hsematocele  are  blows,  wounds,  violent 
muscular  strain,  and  punctures.  In  some  cases  there  is  coincident  effu- 
sion of  blood  into  the  scrotal  tissues. 

Acute  or  traumatic  hsematocele  is  usually  developed  very  rapidly ; 
the  tumor  becomes  enlarged,  hard,  and  painful,  and  the  scrotum  may  be 
cedematous  or  the  seat  of  blood-effusion.  There  are  usually  more  or 
less  constitutional  disturbance  and  pain  from  the  tension  of  the  parts. 
The  effused  blood  often  acts  as  a  foreign  body,  causing  suppurative  in- 
flammation. Again,  the  blood  may  coagulate,  as  it  does  in  aneurism, 
or  it  may  remain  fluid.  Thus  the  course  of  the  affection  is  sometimes 
severe,  and,  on  the  contrary,  when  the  effusion  is  moderate  very  little 
trouble  is  experienced.  If  the  case  runs  a  chronic  course  the  tunica 
vaginalis  may  become  much  thickened. 

The  shape  of  the  tumor  in  vaginal  hsematocele  is  similar  to  that 
of  vaginal  hydrocele.  Translucency  is  not  found  in  any  form  of 
hsematocele. 

The  diagnosis  of  acute  traumatic  hsematocele  is  generally  clear,  the 
history  of  the  case  and  the  local  condition  indicating  its  nature. 

Treatment. — The  patient  must  be  placed  upon  his  back,  the  scrotum 
thoroughly  cleansed  and  irrigated  with  bichloride  solution,  1  to  1000, 
and  then  elevated,  and  cooling  lotions  should  be  applied.  Free  purga- 
tion is  often  beneficial,  and  anodynes  may  be  required  to  relieve  the 
pain.  In  mild  cases  improvement  begins  in  a  few  days,  and  but  little 
suffering  is  experienced.  In  many  cases  the  effusion  continues  and  the 
condition  of  the  patient  renders  an  operation  necessary.  Under  these 
circumstances  it  is  best  to  perform  Yolkmann's  operation  (see  p.  337), 
with  removal  of  the  clots,  and  then  search  for  the  bleeding  vessels. 

Chronic  Form. — Chronic  luematocele  of  the  tunica  vaginalis  testis 


344  AFFECTIONS  OF  THE  TESTIS,   ETC. 

is  a  rare  form  of  chronic  inflammation  of  that  closed  cavity,  and  is  in 
reality  chronic  hydrocele  with  blood-effusion.  The  course  of  this  affec- 
tion is  slow  and,  as  a  rule,  painless.  With  the  progress  of  the  case  more 
or  less  structural  change  takes  place  in  the  vaginal  tunic,  which  becomes 
moderately  and  even  greatly  thickened.  The  blood  contained  in  the 
vaginal  tunic  may  be  fluid,  clotted,  or  coagulated  into  lamina?.  In  pro- 
portion to  the  density  of  the  cell-infiltration  around  the  testis  that  gland 
is  more  or  less  compressed,  and  in  some  instances  atrophy  results. 

This  form  of  hematocele  is  found  usually  in  persons  of  middle  age, 
even  to  the  sixtieth  or  seventieth  year. 

Upon  examination  of  this  form  of  hematocele  we  find  a  rather  large 
round  or  oval  tumor,  with  smooth  walls,  and  having  a  tense  but  elastic 
feel. 

As  a  rule,  the  history  of  the  case  and  the  condition  of  the  tumor  will 
render  a  diagnosis  quite  clear. 

Treatment. — Such  is  the  sluggishness  of  the  course  of  chronic  hema- 
tocele that  patients,  as  a  rule,  do  not  apply  early  for  relief.  As  a  tenta- 
tive measure,  compression  may  be  employed  and  applications  of  mer- 
curial ointment  or  ichthyol  may  be  tried.  When,  owing  to  the  size  and 
weight  of  the  tumor,  it  becomes  evident  that  surgical  intervention  is 
necessary,  we  may  resort  to  Volkmann's  operation  (see  p.  337)  or,  when 
\he  tumor  is  of  very  large  size  and  there  is  evidence  of  testicular  dis- 
organization, it  is  well  to  remove  it. 

Parenchymatous  Hematocele. — This  also  is  a  rare  form  of  acute 
testicular  lesion.  It  is  always  the  result  of  traumatism,  and  consists 
in  a  moderate  effusion  of  blood  into  the  structure  of  the  testis,  and 
perhaps  into  the  epididymis.  Persistent  pain  is  a  marked  symptom. 
The  testis  may  be,  more  or  less  enlarged,  and  in  some  cases  a  small 
area  of  fluctuation  may  be  felt. 

Treatment. — Rest  in  bed,  with  the  scrotum  suspended,  and  the  ap- 
plication of  cooling  lotions,  are  necessary  in  recent  cases.  In  some  cases 
in  which  fluctuation  can  be  felt,  it  may  be  necessary  to  make  a  free 
incision  and  then  pack  the  wound  with  iodoform  gauze.  A  cutting 
operation,  however,  should  not  be  resorted  to  until  all  other  means 

fail. 

Hematocele  of  the  Epididymis  and  Testis. — In  some  very  rare 
instances  the  large  and  small  cysts  seated  around  the  head  of  the 
epididymis  and  upon  the  body  of  the  testis  may  (see  p.  338),  as  a  result 
of  traumatism,  become  the  seat  of  hematocele.  The  parts  then  become 
swollen  and  painful,  but  full  resolution  may  take  place. 

Treatment. — As  a  rule,  rest  in  the  recumbent  position  and  suspen- 
sion of  the  affected  testicle,  together  with  the  application  of  cooling 


STRANGULATION  OF  THE  TESTIS,  ETC.  345 

lotions,  will  cause  subsidence  of  the  affection.  In  chronic  cases  a  modi- 
fied Volkmann's  operation  may  be  necessary. 

Hematocele  of  the  Cord. — Hematocele  of  the  cord  is  very  rare, 
and  may  occur  in  a  diffused  or  in  an  encysted  form. 

Diffused  Hematocele  of  the  Cord. — Diffused  hematocele  occurs 
quite  suddenly  from  rupture  of  a  spermatic  vein  during  violent  exer- 
tion, as  in  lifting  a  heavy  weight,  or  in  consequence  of  a  blow  on  the  parts 
or  during  the  act  of  copulation  and  sudden  intra-abdominal  pressure. 
The  swelling  is  usually  cylindrical,  extending  from  the  upper  part  of 
the  scrotum  to  the  external  ring,  and  may  attain  very  large  proportions. 
The  parts  lying  over  the  tumor  are  unaffected  unless  the  lesion  is  a 
result  of  contusion. 

The  symptoms  of  diffuse  hematocele  of  the  cord  are  sometimes  slight 
and  sometimes  severe.  On  palpation  the  tumor  is  found  to  be  firm 
but  doughy,  with  ill-defined  outlines.  The  course  of  diffused  hemato- 
cele of  the  cord  is,  under  favorable  circumstances,  toward  gradual  sub- 
sidence ;  in  some  instances  severe  inflammatory  action  is  set  up.  Ulti- 
mately the  cord  is  left  in  a  normal  condition  or  perhaps  a  little 
thickened. 

The  diagnosis  of  diffuse  hematocele  of  the  cord  usually  offers  no 
difficulty.  The  history,  position,  and  general  features  of  the  swelling  are 
unmistakable.  An  important  point  is  the  absence  of  impulse  on 
coughing. 

Treatment. — During  the  acuteness  of  the  affection  the  patient  should 
remain  in  bed  and  cooling  lotions  should  be  applied  to  the  part.  In 
the  chronic  condition,  blisters  may  be  freely  used  and  graduated  pres- 
sure may  be  tried.     As  a  rule,  full  absorption  of  the  exudates  occurs. 

Encysted  Hematocele  of  the  Cord. — Encysted  hematocele  of  the 
cord  is  very  rare,  and  is  due  to  effusion  of  blood  into  a  cyst  or  an 
encysted  hydrocele  in  consequence  of  injury.  The  resulting  tumor  is 
small  and  round  or  oval,  but  is  not  translucent.  As  a  rule,  encysted 
hydrocele  of  the  cord  is  unattended  with  marked  symptoms. 

Treatment. — When  the  encysted  hematocele  is  large  enough  to 
cause  discomfort  it  may  be  necessary  to  make  an  incision  into  it,  to 
turn  out  its  contents  and  pack  its  cavity  with  iodoform  gauze,  all  being 
done  with  strict  antisepsis. 

STRANGULATION   OF    THE   TESTIS   AND   EPIDIDYMIS 
FROM   TORSION   OF   THE   CORD. 

There  are  in  medical  literature  less  than  twenty-five  cases  recorded 
in  which  the  testicle,  seated  either  in  the  inguinal  canal  or  just  in 
the  scrotum,  became  acutely  swollen  and  painful  as  a  result  of  tor- 
sion of  the  spermatic  cord.     Of  these  cases  the  majority  were  those  of 


346  AFFECTIONS  OF  THE  TESTIS,   ETC. 

boys  from  thirteen  to  twenty-one  years  old,  while  in  the  great  minority 
were  old  men  and  young  children.  In  most  of  the  cases  there  is  a  his- 
tory or  evidence  of  undescended  or  imperfectly  descended  testis ;  con- 
sequently, as  a  rule,  the  swelling  is  found  in  the  inguinal  canal  or  just 
within  the  upper  part  of  the  scrotum.  The  objective  symptoms  are 
localized  swelling,  oedema,  and  redness.  The  subjective  symptoms  are 
varied,  and  they  may  point  to  strangulation,  hernia,  traumatism,  or 
inflammation  of  the  appendix  vermiformis.  These  are  pain,  fever,  and 
frequently  constipation  and  vomiting,  which,  however,  is  not  stercora- 
ceous.  As  distinguished  from  hernia,  it  will  be  noted  that  the  consti- 
pation is  not  so  persistent,  the  shock  is  decidedly  less,  and  there  are  no 
abdominal  symptoms.  The  tumor  is  harder  than  that  of  hernia,  and  is 
absolutely  without  impulse  and  is  irreducible.  Though  the  location  and 
quite  sharp  localization  of  the  tumor,  together  with  its  history  and  con- 
comitant symptoms,  point  very  convincingly  to  the  testis  (and  it  is 
absent  from  the  scrotum  in  the  majority  of  cases),  it  sometimes  happens 
that  a  diagnosis  is  not  arrived  at  until  an  exploratory  incision  has  been 
made.  Then  the  testis  and  epididymis  are  found  to  be  swollen,  of  a 
deep-blue  or  even  black  color  from  hemorrhagic  infarction,  and  some- 
times it  is  gangrenous.  .  When  the  tumor  is  below  the  internal  ring 
the  finger-tip  pressed  over  that  part  will  show  that  the  case  is  not  one 
of  hernia.  Hernia  may  be  found  as  a  complicating  condition  of  this 
accident  to  the  testis. 

The  exciting  causes  of  torsion  of  the  cord  are,  in  the  main,  excessive 
labor  and  violent  and  sudden  strain.  In  some  of  the  reported  cases  no 
exciting  cause  whatever  could  be  ascertained,  and  in  some  instances  the 
condition  developed  while  the  patient  was  asleep. 

Usually  torsion  of  the  cord  leads  to  destruction  of  the  testicle  unless 
promptly  relieved. 

The  twist  of  the  cord  may  be  partial  or  complete,  or  the  cord  may  be 
twisted  several  turns.  The  essential  and  underlying  cause  of  torsion  of 
the  cord  is  due  to  disturbance  in  the  development  of  the  vaginal  process 
of  the  peritoneum,  in  which  the  mesorchium  is  either  too  slender  or  too 
long,  and  hence  does  not  give  the  testis  the  necessary  amount  of  fixation. 
The  mesorchium  then  allows  greater  movement  than  normal,  and  the 
testis  may,  as  a  result,  encounter  difficulty  in  entering  the  inguinal  canal 
and  impediment  in  traversing  it.  When  it  is  in  the  inguinal  canal  the 
flat  condition  of  the  organ  militates  against  its  replacement,  and  renders 
this  impossible  as  soon  as  inflammation  has  become  established. 

Treatment, — AVhen  it  occurs  in  the  scrotal  sac,  torsion  of  the  cord 
may  be  reducible  by  taxis.  Hemorrhagic  infarction  of  the  testis  and 
epididymitis  calls  for  prompt  incision  and  extirpation. 


EPIDID  YMO-  OR  CHITIS.  347 

EPIDIDYMO-ORCHITIS    FROM    URETHRAL    EXPLORATIONS 

AND  OPERATIONS. 

The  introduction  of  bougies,  sounds,  and  catheters  into  the  urethra 
for  various  conditions  is  not  infrequently  followed  by  epididymitis  or 
epididymo-orchitis.  In  the  course  of  gradual  dilatation  for  stricture 
and  for  chronic  urethritis,  as  a  result  of  catheterism  in  retention  of  urine 
in  acute  gonorrhoea  and  gonorrhceal  congestion  of  the  prostate,  and  in 
the  retention  which  sometimes  follows  severe  operations,  chiefly  about 
the  rectum  and  abdomen,  and  also  elsewhere,  inflammation  of  the  tes- 
ticle sometimes  occurs.  In  young  and  old  subjects,  upon  whom  lith- 
otrity,  litholopaxy,  and  lithotomy  have  been  performed,  the  testicle  may 
become  damaged.  This  accident  not  infrequently  occurs  when  a  cathe- 
ter or  other  instrument  is  tied  in  the  bladder. 

In  cases  of  hypertrophy  of  the  prostate,  in  which  the  necessity  for 
the  introduction  of  the  catheter  is  more  or  less  urgent,  testicular  inflam^ 
mation  is  not  very  uncommon.  In  many  of  these  cases  the  testicular 
complication  may  be  traced  to  the  use  of  too  large  a  catheter,  to  one 
which  has  by  age  become  rather  rough,  and  often  to  dirt  which  has  been 
carried  on  the  catheter  owing  to  the  patient's  carelessness. 

While,  in  general,  the  symptoms  of  this,  as  we  may  call  it,  traumatic 
epididymo-orchitis  resemble  those  of  gonorrhoea,  they  present  certain 
somewhat  distinctive  features.  As  a  rule,  the  testicular  inflammation 
comes  on  quite  promptly  after  the  receipt  of  the  injury.  Then,  again, 
the  onset  may  not  occur  for  several  days,  and  then  may  be  slow,  halt- 
ing, and  intermittent.  In  the  cases  where  the  inflammation  is  slow  in 
development  its  course  is  usually  prolonged,  and  resolution  comes  on 
rather  tardily.  In  some  cases,  however,  the  invasion  is  rapid  and 
brusque,  and  in  these  particular  cases  we  not  unfrequently  observe  quite 
prompt,  even  markedly  rapid,  resolution. 

The  physical  signs  differ  in  various  cases  according  to  the  mode  of 
invasion.  In  the  slowly-developing  cases  the  patient  may  suffer  little 
pain,  and  may  discover,  sometimes  by  accident,  that  the  tail  or  head  of 
the  epididymis  is  somewhat  swollen,  hard,  and  perhaps  a  little  tender  on 
pressure.  The  swelling  may  then  increase  slowly,  limited  to  one  part 
of  the  epididymis,  or  it  may  spread  and  involve  the  whole  of  it.  It  then 
feels  like  a  hard,  firm,  quite  bulky  crescent  seated  on  the  testis.  This 
condition  may  remain  indolent  for  a  varying  period,  and  it  may  quite 
fully  disappear,  or  it  may  lead  to  a  permanent  swelling  and  induration 
of  the  epididymis.  There  may  be  a  concomitant  moderate  effusion  into 
the  tunica  vaginalis. 

The  course  of  the  case  in  which  the  onset  is  brusque  and  rapid  is,  in 
the  main,  quite  like  that  of  acute  gonorrhoeal  epididymo-orchitis.  Ab- 
scess, however,  is  more  frequent  than  in  the  latter  condition. 


348  AFFECTIONS  OF  THE  TESTIS,   ETC. 

In  a  goodly  proportion  of  young  and  middle-aged  patients  this  post- 
instrumental  inflammation  is  limited  to  the  testicle,  with  sometimes  the 
involvement  of  the  tunica  vaginalis.  In  a  rather  larger  proportion  the 
epididymis  is  attacked.  In  elderly  and  very  old  men,  while  the  process 
may  be  limited  to  the  epididymis,  it  more  commonly  attacks  the  testis 
also.  In  these  cases  the  epididymo-orchitis  may  be  slow  in  development 
or  the  onset  may  be  quite  rapid.  When  the  testis  is  involved  there  is 
usually  much  pain. 

Abscess  of  the  epididymis,  of  the  tunica  vaginalis,  and  particularly 
of  the  parenchyma  of  the  testis,  is  a  not  uncommon  accident.  Abscess 
of  the  testis  in  old  men  may  lead  to  the  total  extrusion  of  the  gland  and 
its  appendages.  This  sequela  may  be  quite  rarely  observed  in  young 
and  middle-aged  men. 

The  treatment  is  the  same  as  is  directed  for  gonorrheal  epididymo- 
orchitis.     (See  p.  121  et  seq.) 

ORCHITIS  DUE  TO  MUSCULAR  CONTRACTION. 

So  many  cases  have  been  reported  in  which  epididymitis  and  orchitis, 
separately  or  combined,  have  developed  as  a  result  of  muscular  injury 
that  to-day  this  causative  factor  is  quite  generally  admitted.  In  these 
cases  the  pain  on  the  receipt  of  the  injury  may  be  at  first  slight,  and 
may  gradually  become  severe,  or  it  may  be  violent  and  sickening  from 
the  first. 

In  most  cases  the  left  testis  is  affected,  and  the  clinical  picture  re- 
sembles that  of  gonorrheal  inflammation  of  these  parts. 

There  is  considerable  divergence  of  opinion  as  to.  the  mechanism  of 
the  traumatism  in  these  cases,  in  which  patients  slipping  with  violence, 
lifting  heavy  weights,  and  by  any  means  rudely  shaken  become  attacked 
by  testicular  pain  and  inflammation. 

According  to  one  view,  violent  contraction  of  the  abdominal  muscles, 
particularly  of  the  fibres  of  the  rectus  abdominalis  muscle,  which  are 
present  in  arched  form  over  the  cord  at  the  external  abdominal  ring, 
injures  the  cord,  and  the  inflammation  then  descends  to  the  testis. 

Another  view  held  is  that  the  injury  results  from  violent  contraction 
of  the  cremaster  muscle,  which  jerks  the  testis  against  the  pillars  of  the 
external  rings  by  what  is  called  a  whip-snap  action. 

In  all  probability  the  mechanism  of  the  injury  is  as  follows  :  Owing 
to  violence  in  coughing,  straining,  or  to  sudden  wrenching  of  the  body, 
the  abdominal  parietes  and  diaphragm  contract  and  thus  bring  strong 
pressure  to  bear  on  the  spermatic  plexus  of  veins,  which  are  poorly 
provided  with  valves  and  loosely  surrounded  with  connective  tissue. 
As  a  result,  rupture  of  the  veins  may  occur  in  the  cord,  in  the  epididy- 
mis, or  in  the  substance  of  the  testis. 


ORCHITIS  AND  EPIDIDYMO-ORCHITIS.  349 

111  addition  to  this  action,  spasmodic  contraction  of  the  cremaster 
and  of  the  fibres  of  the  rectus  muscle  may  also,  in  some  cases,  play  an 
accessory  part.  In  many  cases  of  this  form  of  orchiepididymitis  the 
patients  have  previously  been  free  from  venereal  diseases,  gonorrhoea 
especially.  There  can  be  no  doubt  that  a  latent  subacute  inflammatory 
condition  of  the  testis  or  cord  may  be  transformed  into  an  acute  condi- 
tion by  means  of  muscular  traumatism. 

This  form  of  testicular  trouble  usually  goes  on  promptly  to  resolu- 
tion, though  induration  of  the  epididymis  and  enlargement  of  the  testicle 
may  result. 

The  treatment  is  the  same  as  is  directed  for  gonorrhceal  epididymo- 
orchitis.     (See  p.  121  et  seq.) 

ORCHITIS    AND   EPIDIDYMO-ORCHITIS    DUE    TO  VARIOUS 
INFECTIOUS  DISEASES. 

Inflammation  of  the  testicles,  alone  or  in  combination  with  epididy- 
mitis and  vaginalitis,  may  also  occur  as  a  complication  of  a  number  of 
infective  diseases. 

In  the  course  of  mumps  the  testicle  may  become  painful,  swollen,  and 
hard.  The  affection  called  mumps,  or  parotidian  orchitis,  may  be  limited 
to  the  gland  and  it  may  involve  the  epididymis  and  the  tunica  vaginalis. 
The  onset  of  this  inflammation  is  brusque  and  its  course  rapid,  so  that 
in  from  three  days  to  a  week  it  may  cease.  Involvement  of  the  second 
testicle  sometimes  occurs.  In  this  form  of  orchitis  resolution  may  be 
perfect,  but  not  uncommonly  total  atrophy  occurs. 

During  the  course  of  small-pox  the  testicle,  its  tunica,  and  its  append- 
ages may  be  attacked  with  more  or  less  violent  inflammation.  This 
complication  may  occur  in  men  who  have  previously  suffered  from 
gonorrhoea  and  in  those  who  have  not. 

Orchitis  accompanied  by  epididymitis  and  vaginalitis  is  a  very  rare 
complication  of  scarlet  fever.  Two  cases  have  been  reported  as  occur- 
ring in  boys  six  and  eight  years  old. 

There  have  been  so  many  cases  reported  in  which  orchitis  developed 
during  malarial  fever,  and  for  which  no  other  pathogenic  cause  or  con- 
dition can  be  assigned,  that  it  seems  reasonable  to  accept  the  latter  as 
cause  and  the  former  as  effect.  One  testis  or  both  may  be  attacked. 
The  clinical  picture  is  that  of  acute  orchitis.  The  tendency  of  the  dis- 
ease is  to  quite  prompt  resolution,  after  which,  in  some  cases,  atrophy 
may  occur  and  an  indurated  epididymis  may  be  left.  The  pain  incident 
to  this  inflammation  is  usually  severe,  sometimes  continuous,  and,  again, 
it  may  be  intermittent.  Quinine  has  an  excellent  effect  in  aborting  and 
causing  the  resolution  of  this  inflammatory  process. 

There  is  abundant  evidence  to  prove  that  influenza,  or  la  grippe, 


350  AFFECTIONS  OF   THE   TESTIS,   ETC. 

may  be  the  exciting  cause  of  orchitis  in  subjects  who  have  never 
suffered  from  gonorrhoea  or  any  inflammation  of  the  urinary  tract. 
This  infectious  disease  also  has  been  known  to  cause  recrudescences  of 
epididymitis  and  orchitis  in  organs  previously  the  seat  of  gonorrhoeal 
inflammation.  The  physical  signs  generally  are  those  of  acute  gonor- 
rhoea! inflammation,  but,  as  a  rule,  resolution  occurs  more  promptly. 

In  some  cases  of  grip-orchitis  there  is  a  mild  mucopurulent  urethral 
discharge. 

When  uncomplicated  these  testicular  affections  due  to  grip  run  an 
acute  course  and  quite  rapidly  go  on  to  complete  resolution. 

During  the  course  of  pneumonia  and  for  some  time  after  its  deferves- 
cence inflammation  of  the  testicle  or  epididymis  may  occur  as  a  result 
of  that  infective  process. 

Testicular  inflammation  occurs  somewhat  rarely  during  the  course 
of  typhoid  fever,  Leibermeister  having  found  two  instances  in  200 
cases.  Generally,  it  is  toward  the  end  of  the  fever  that  the  epididymis 
is  attacked,  either  in  a  subacute  or  a  brusquely  acute  manner.  There 
is  usually  a  concomitant  rise  in  the  temperature  and  an  ephemeral  return 
of  the  general  symptoms.  In  some  cases  this  complication  appears 
early  in  the  disease,  and  in  others  after  full  defervescence  and  cure. 

Usually  this  form  of  epididymitis  is  unilateral,  and  resolution  takes 
place  slowly,  leaving  no  trace  after  it.  Then,  again,  induration  has 
been  known  to  follow.  In  some  cases  the  testis  and  vas  deferens  are 
attacked. 

Several  cases  have  been  reported  in  which  during  typhoid  fever 
chronic  urethritis  has  undergone  recrudescence,  and  epididymo-orchitis 
has  resulted. 

During  the  course  of  pysemia  and  of  grave  phlegmonous  inflamma- 
tion in  bones  orchitis  may  supervene. 

It  is  claimed  by  some  authors  that  during  and  following  the  course 
of  tonsillitis,  whooping-cough,  acute  articular  rheumatism,  and  gout  an 
inflammation  of  the  testicle  etiologically  related  to  these  morbid  condi- 
tions may  occur.  The  treatment  of  these  anomalous  forms  of  testicular 
inflammation  is,  in  the  main,  that  directed  for  gonorrhoeal  epididymo- 
orchitis.     (See  p.  121  et  seg.) 

CHRONIC   ORCHITIS  AND  EPIDIDYMITIS. 

The  testis  and  the  epididymis  are  liable  to  be  attacked  by  such 
a  degree  of  chronic  inflammation  in  young,  middle-aged,  and  old  sub- 
jects that  the  function  of  the  gland  may  be  destroyed  by  the  indurating 
and  atrophic  processes  which  supervene.  In  many  of  these  cases  there 
has  existed  as  a  starting-point  gonorrhoeal  epididymitis,  or  epididymo- 


CHRONIC  ORCHITIS  AND  EPIDIDYMITIS. 


351 


orchitis ;  in  some,  however,  the  gland  had  previously  been  healthy.  In 
none  of  them  is  tubercular  infection  an  exciting  or  predisposing  cause. 
In  some  cases  of  chronic  posterior  urethritis  and  of  stricture  of  the 
urethra,  usually  in  careless  sexually  indulgent  subjects,  the  epididymis 
and  in  some  cases  the  testis  may  be  attacked  by  a  mild  form  of  inflam- 
mation, which  does  not  cause  the  patient  to  go  to  bed,  or  these  struct- 
ures to  become  much  swollen  or  painful.  Such  an  attack  usually  soon 
subsides,  and  is  followed  at  a  greater  or  less  interval  of  time  by  a  recru- 
descence, which  in  its  turn  is  followed  by  another  attack,  and  so  the 
case  continues  for  years.  Some  relapses  are  more  severe  and  inflam- 
matory than  others.  When  examined,  such  an  epididymis  is  found  to 
be  enlarged  usually  in  its  whole  length,  the  swelling  being  quite  uniform 


Fig.  90. 


Chronic  orchitis  and  epididymitis. 

and  diffuse  and  not  nodulated  at  any  point.  (See  Fig.  90.)  Thus  is 
produced  a  hard,  firm,  perhaps  painless,  sclerotic  crescent,  which  is 
attached  to  the  back  and  upper  and  lower  part  of  the  gland.  The  lesion 
not  being  of  a  tubercular  nature,  degenerative  changes,  such  as  abscesses 
and  necrosis,  are  not  observed,  but  as  time  goes  on  the  sclerosis  gradually 
destroys  the  efferent  spermatic  tubes  and  produces  azoospermatism  of  one 


352  AFFECTIONS  OF  THE  TESTIS,  ETC. 

and  not  infrequently  of  both  sides.  The  testis,  when  it  is  attacked,  may- 
become  rather  larger  than  normal  or  it  may  decrease  in  size.  As  a  rule, 
patients  thus  affected  being  young  and  well,  and  observing  for  a  long 
period  no  diminution  in  their  sexual  desires  and  in  their  ability  for 
copulation,  pay  little  heed  to  their  testicular  trouble.  Later  on,  in 
cases  of  double  epididymitis  or  epididymo-orchitis,  the  sexual  appetite 
and  the  capacity  for  coitus  may  begin  to  wane,  and  the  affection  becomes 
a  source  of  anxiety  and  apprehension.  In  the  case  of  unilateral  involve- 
ment there  may  be  no  functional  impairment  unless  the  unaffected  testis 
becomes  diseased  from  any  cause. 

This  form  of  chronic  epididymo-orchitis  being  so  persistent,  so  liable 
to  undergo  exacerbation,  and  so  rebellious  to  treatment,  is  really  a 
serious  affair,  and  it  calls  for  careful  local  and  urethral  treatment. 

The  clinical  picture  above  portrayed  will  apply  to  cases  of  young 
and  old  subjects  usually  having  chronic  gonorrhoea  or  stricture  of  the 
urethra,  in  whom  it  is  necessary  to  pass  for  long  periods  of  time 
urethral  instruments ;  also  to  cases  in  which  lithotrity,  litholapaxy, 
and  lithotomy  have  been  performed.  In  these  cases,  however,  abscess 
of  the  testis  may  occur. 

In  some  old  men  having  hypertrophy  of  the  prostate,  cystitis,  and 
that  low-grade  form  of  chronic  gonorrhoea  which  is  not  uncommon,  a 
slow,  usually  painless  fibroid  enlargement  of  the  whole  epididymis, 
and  perhaps  of  the  testis,  may  not  uncommonly  be  observed.  In  nearly 
all  the  cases  in  which  the  testis  is  the  seat  of  chronic  enlargement 
there  is  more  or  less  involvement  of  the  epididymis,  but  the  latter 
structure  may  be  attacked  without  there  being  any  perceptible  change 
in  the  testis  itself. 

Treatment. — In  those  cases  in  which  chronic  orchitis  and  epididy- 
mitis seem  to  have  been  caused  and  perpetuated  by  such  urethral  lesions 
as  chronic  urethritis  and  stricture,  the  essential  point  is  to  treat  these 
conditions  locally  and  to  cure  them.  Cases  in  elderly  men  in  which 
prostatic  hypertrophy  is  an  exciting  cause  should  receive  treatment 
directed  to  the  prostate.  When  surgical  operations  (lithotomy,  lithot- 
rity, and  litholapaxy)  have  been  followed  by  inflammation  and  con- 
gestion of  the  prostatic  urethra,  complicated  with  testicular  involve- 
ment, systematic  topical  treatment  of  the  urethral  canal  is  imperative. 

All  patients  suffering  from  chronic  orchitis  or  epididymitis  should 
wear  a  nicely-fitting  suspensory  bandage  at  all  times  during  the  day. 
(For  local  treatment  of  the  testicle,  see  p.  124  et  seq.) 


TUBERCULOSIS.  353 


ATROPHY. 


Atrophy  of  the  testis  is  not  very  uncommon,  and  is  due  to  a  great 
variety  of  causes. 

In  the  young  subject  the  gland  may  become  dwarfed  by  reason  of 
abnormal  retention  and  of  malposition  or  ectopia.  In  old  subjects, 
senile  changes  begin  earlier -in  the  testis  than  in  other  parts  of  the  body, 
and  the  organ  may  be  reduced  to  a  mere  mass  of  fibrous  tissue  with- 
out any  trace  of  glandular  structure. 

As  a  complication  in  the  course  of  a  number  of  infectious  diseases  the 
testis  is  not  infrequently  involved,  and  the  outcome  is  very  often  atrophy 
or  structural  degeneration. 

Gonorrhoea  may,  in  rather  exceptional  cases,  end  in  testicular  atrophy, 
but  its  danger  to  the  sexual  capacity  resides  in  its  tendency  to  occlude 
the  spermatic  tubes. 

Syphilis  is  a  potent  and  frequent  factor  in  the  production  of  atrophy 
of  the  testis  and  of  the  epididymis,  and  occupies  a  prominent  place  in 
the  category  of  causes  of  sexual  impairment  and  sterility. 

Hydrocele  and  hematocele  may  lead  to  moderate  and  temporary  or 
permanent  azoospermatism  by  reason  of  the  structural  atrophic  changes 
which  they  produce  in  the  testis  and  epididymis. 

It  is  doubtful  whether  varicocele  produces  true  atrophy  of  the  testis, 
except  in  very  rare  instances. 

In  a  certain  number  of  cases  of  elephantiasis  of  the  scrotum  true 
atrophy  of  the  testis  has  been  observed.  In  some  forms  of  hemiplegia, 
general  paresis,  and  in  some  cases  of  traumatism  of  the  skull,  brain, 
cerebellum,  medulla  oblongata,  and  spinal  cord,  wasting  of  the  testes  is 
observed.  In  these  cases  the  spinal  sexual  centre  is  so  affected  that  its 
function  is  destroyed.  The  long-continued  use  of  iodide  and  bromide 
of  potassium  and  belladonna  has  been  stated  to  be  the  cause  of  atrophy 
of  the  testis. 

TUBERCULOSIS. 

Tubercular  infiltration  is  one  of  the  most  common  affections  which 
attacks  the  testis  and  destroys  its  function.  It  is  observed  chiefly  at 
and  during  puberty  and  in  adult  life,  but  may  be  found  in  infants,  and 
much  less  frequently  in  middle-aged  and  elderly  men. 

In  all  probability,  tubercle  of  the  testis  is  developed  secondarily  to 
some  other  more  or  less  remote  focus  of  infection  of  the  body,  and  it  is 
chiefly  noted  as  being  found  in  association  with  tuberculosis  of  the 
prostate,  seminal  vesicles,  and  bladder  and  ureters  and  kidneys.  Though 
some  cases,  from  a  clinical  standpoint,  seem  to  be  instances  of  primary 
testicular  tuberculosis,  it  is  not  well  to  venture  such  a  diagnosis  with 

23 


354  AFFECTIONS  OF  THE  TESTIS,  ETC. 

much  positiveness,  since  lurking  and  perhaps  dormant  foci  of  infection 
may  exist  in  some  part  of  the  body  which  can  only  be  detected  by  post- 
mortem examination. 

As  to  the  avenues  by  which  the  testis  is  invaded,  it  may  be  stated 
that  clinical,  anatomical,  and  pathological  facts  point  to  the  bloodvessels 
as  the  carriers  of  the  infective  material. 

There  is  no  scientific  evidence  at  hand  in  favor  of  the  view  that  pri- 
mary infection  through  the  urethral  canal  may  in  some  obscure  way 
occur  and  lead  to  testicular  invasion. 

There  is  good  reason  for  supposing  that  infection  of  the  seminal  vesi- 
cles and  prostate  may  occur  through  the  vesico-rectal  peritoneal  fold 
from  tuberculosis  of  the  peritoneum. 

In  clinical  practice  we  find  two  quite  clearly  marked  forms  of  tuber- 
cle of  the  testis — namely,  the  acute  and  the  chronic  forms.  Besides  these 
forms  we  find  mixed  varieties,  in  which  acuity  and  chronicity  are 
blended. 

The  acute  form  of  tuberculosis  of  the  testis  presents  somewhat  the 
same  clinical  picture  as  is  oifered  by  acute  gonorrhceal  epididymitis. 
The  patient  may  have  given  evidence  of  tuberculosis  in  some  other  and 
perhaps  remote  organ  ;  he  may  or  may  not  have  complained  of  bladder, 
prostate,  or  urethral  disorder ;  and  he  may  or  may  not  have  suffered 
from  gonorrhceal  epididymo-orchitis.  He  may  have  previously  enjoyed 
good  or  fairly  good  health,  or  the  testicular  lesion  may  appear  as  the  only 
local  evidence  of  disease  in  a  man  who  is  pale,  weak,  and  sickly,  and 
who,  perhaps,  has  within  a  short  time  lost  flesh.  In  many  cases  trau- 
matism seems  to  be  the  exciting  cause. 

Usually  the  first  symptom  is  pain  seated  in  the  head  or  the  tail  of 
the  epididymis,  and  very  soon  the  segment  involved  swells  to  consider- 
able size.  In  some  galloping  cases  the  whole  epididymis  is  much 
swollen  in  all  directions,  is  either  spontaneously  painful  or  on  slight 
pressure,  and  is  covered  with  an  acutely  inflamed  area  of  scrotal  tissue 
in  a  day  or  two.  In  other  cases  several  days  or  even  two  or  three 
weeks  elapse  before  such  an  acute  condition  is  reached.  In  these  cases 
there  is  usually  more  or  less  fever  and  malaise.  "When  palpated  in  this 
state  the  epididymis  usually  does  not  present  any  diagnostic  points,  and 
the  conclusion  may  be  reached,  if  there  is  any  evidence  of  urethral  dis- 
charge, that  the  case  is  one  of  gonorrhceal  epididymo-orchitis  in  the 
declining  or  chronic  stage.  "When  the  entire  absence  of  any  urethral 
discharge  or  affection  is  rendered  clear,  the  suspicion  of  tubercular  inva- 
sion may  be  entertained. 

In  a  few  days  or  in  a  week  or  two,  upon  the  subsidence  of  the  severe 
inflammatory  reaction  (in  cases  in  which  an  abscess  has  not  been  formed, 
and  in  which  vaginalitis  has  not  developed),  the  surgeon  can  carefully 


TUBERCULOSIS.  355 

examine  the  organ,  and  then,  or  perhaps  later,  a  nodular  or  bossy  con- 
dition of  the  head  and  tail  and  perhaps  of  the  body  of  the  epididymis 
may  be  clearly  made  out.  At  this  time  the  testis  may  appear  unin- 
volved,  but  later  on  it  may  become  more  or  less  enlarged,  and  on  its 
surface  small  or  large  nodulations,  just  as  if  small  shot  or  split  peas 
were  seated  in  the  tissue,  can  be  felt. 

It  sometimes  happens  that  the  seminal  fluid  becomes  of  a  rose  color 
from  blood  admixture,  probably  deriyed  from  some  part  of  the  testis. 
Abscess  may  sooner  or  later  develop,  usually  at  the  head  of  the  epidid- 
ymis, and  also  at  the  tail.  When  the  tail  of  the  epididymis  is  attacked 
it  is  not  uncommon  to  find  a  mass  of  suppurating  tissue  about  an  inch 
or  less  from  it  and  connected  by  a  fibrous  strand  in  the  loose  scrotal 
tissue.  These  extra-epididymal  abscesses  seem  to  be  due  to  infecting 
pus  which  escapes  from  the  involved  epididymis. 

Abscess  is  the  direct  outcome  of  the  caseation  and  softening  of  the 
tubercular  inflammation.  The  non-vascular  cellular  nodules  produced 
by  the  infective  process,  and  the  infiltration  which  surrounds,  com- 
presses, and  destroys  the  seminal  tubules  and  leads  to  a  chronic  diffuse 
orchitis,  break  down  and  give  issue  through  one  or  several  fistulse  to  a 
thin  fluid  streaked  with  pus  and  small  grumous  masses.  The  scrotal 
wall  becomes  of  a  deep  red,  even  of  a  bluish-red,  color,  and  the  orifices 
of  the  fistulse  look  very  unhealthy.  In  the  cases  thus  briefly  described 
there  is  usually  more  or  less  destruction  of  the  testis  proper,  but  the 
function  of  the  gland  is  promptly  destroyed  by  the  deadly  infective 
invasion  which  attacks  it  in  its  centre  and  on  both  flanks.  One  testis 
may  be  thus  attacked,  but  not  very  frequently  the  other  one  is  sooner 
or  later  involved. 

In  the  chronic  form  of  tuberculosis  of  the  testis  many  clinical  pictures 
are  presented.  In  some  cases,  in  apparently  healthy  or  in  sickly-look- 
ing subjects,  with  or  without  coexisting  urethral,  prostatic,  and  vesicular 
involvement,  the  epididymis  (tail  or  head)  swells  painlessly,  and  the 
patient  by  accident  discovers  a  small  pea-sized  or  hickory-nut-sized 
nodule  of  irregular  outline.  This  condition  may  slowly  increase,  and  as 
it  does  the  infiltration  becomes  more  rugose  upon  its  surface,  and  it  may 
extend  to  the  whole  epididymis,  converting  it  into  a  fibrous  mass.  In 
this  painless  indolent  state  it  may  remain  for  a  long  time — months  or 
years — or  caseation,  softening,  and  fluctuation  may  be  discovered,  or 
abscess  or  fistula  may  develop.  On  removal  of  such  a  testis  the  epidid- 
ymis is  found  to  be  very  tough  and  fibrous,  with  here  and  there  cavities 
in  which  degeneration  has  occurred.  Very  often  no  evidence  of  inva- 
sion  of  the  testis  can  be  found. 

In  other  chronic  cases  there  may  be  synchronously  observed  separate 
nodules  of  small  or  large  size  in  the  head  and  tail  of  the  epididymis, 


356  AFFECTIONS   OF  THE  TESTIS,   ETC. 

with  what  is  then  most  common,  the  involvement  of  the  whole  medias- 
tinum testis.  In  these  cases  the  disease  may  remain  latent  and  indolent 
for  varying  periods  (often  quite  long  ones),  or  exacerbations  may  occur, 
and  the  case  in  its  course  may  then  resemble  those  of  acute  develop- 
ment. In  general,  however,  the  infective  process  goes  on,  the  chronic 
epididymo-orchitis  keeps  on  its  course,  and  then  we  find  a  much  en- 
larged epididymis,  which  is  hard,  knobby,  and  irregular.  In  some 
cases  the  lesion  in  the  epididymis  preponderates,  and  then  that  append- 
age is  very  large  indeed,  and  the,  as  yet,  uninvaded  testis  forms  but  a 
small  portion  of  the  morbid  tumor.  Then,  again,  the  growth  in  the 
testis  keeps  pace  with  the  process  in  the  epididymis,  and  a  large  mass  is 
produced.     (See  Plate  XII.) 

Hydrocele  is  observed  in  about  one-third  of  the  cases  of  tubercle  of 
the  testis.  In  some  exceptional  cases  tuberculosis  of  the  testis  (one  or 
both)  presents  the  same  clinical  picture  as  is  offered  by  syphilitic  sarco- 
cele.  By  slow  degrees,  with  some  or  little  pain,  the  testis  and  epidid- 
ymis enlarge  and  form  an  ovoid  or  pear-shaped  tumor,  which  has  a 
smooth  surface  and  hard,  firm  consistence,  and  which  may  be  mistaken 
for  syphilitic  sarcocele  or  cystic  sarcoma  of  the  testis.  These  tubercular 
testes  may  be  as  large  as  a  good-sized  pear  or  as  a  large  fist.  They  may 
remain  intact  for  a  long  period,  and  they  may  become  the  seat  of  abscess 
and  fistula  and  of  fungoid  development.  In  some  of  these  cases  I  have 
observed  small  and  large  rounded  nodulations  on  the  surface  of  the  testis. 
It  is  always  difficult  and  often  impossible  in  this  form  of  tuberculosis  of 
the  testis  to  discover  the  epididymis  or  to  settle  in  one's  mind  how 
much  it  contributes  to  the  general  swelling,  since  the  parts  are  so  inti- 
mately merged  together. 

The  life-history  of  patients  suffering  from  tubercle  of  the  testis  is 
that  of  tuberculosis  in  general.  In  some  cases  the  patients  live  for 
years  after  the  extirpation  of  the  organ  or  organs  ;  in  others  death  fol- 
lows sooner  or  later  from  extension  of  the  disease  to  vital  organs. 

Besides  the  strikingly  well-marked  features  presented  by  the  affected 
testis,  there  is,  in  most  cases,  evidence  of  prostatic  involvement  in  the 
shape  of  enlargement  and  large  and  small  nodulations,  and  perhaps  of 
irregular  infiltrations  in  the  ampullated  ends  of  the  vasa  deferentia  and 
of  the  seminal  vesicles,  which  may  be  ascertained  by  digital  examina- 
tion in  the  rectum. 

In  many  cases  of  tubercular  testis  the  scrotal  part  of  the  vas  deferens 
is  more  or  less  attacked.  There  may  be  slight  thickening  and  enlarge- 
ment, circumscribed  or  diffuse,  or  the  tube  may  be  so  nodulated  that  it 
feels  like  a  string  of  beads  of  various  sizes.  A  testis  attacked  by  tuber- 
culosis soon  ceases  to  possess  the  spermatogenic  function. 

In  all  probability,  tubercular  invasion  of  the  epididymis  and  testis 


PLATE  XII. 


TUBERCULOSIS  OF  THE  TESTICLE  AND   EPIDIDYMIS. 


CYSTIC  SARCOMA.  357 

destroys  the  function  of  the  gland  much  sooner  and  more  frequently 
than  we  have  heretofore  thought.  It  must  be  remembered  that  even 
in  mild  and  indolent  cases  the  development  of  toxins  occurs  in  associa- 
tion with  the  morbid  tissue-changes,  and  these  poisons  permeate  the 
structures  of  the  testis  and  destroy  the  delicate  arrangement  by  which  the 
spermatogenic  function  is  performed.  In  very  acute  cases  the  extensive 
swelling  and  hyperemia  are  undoubtedly  largely  due  to  the  diffusion  of 
the  poisons  through  the  whole  gland.  It  is  fair  to  assume  that  this 
condition  destroys  the  function  of  the  testis  at  once.  Then,  in  addition 
to  this  diffusible  poison,  the  cell  changes  so  destroy  the  integrity  of  the 
gland  that  it  soon  becomes  useless  as  a  producer  of  spermatozoa. 

Involvement  of  the  two  glands  carries  with  it  sterility.  The  fore- 
going considerations  show  what  a  widely  deleterious  influence  tubercu- 
losis exerts  upon  the  sexual  function. 

Treatment. — The  most  important  point  in  the  management  of  cases 
of  tuberculous  testes,  and  in  which  other  organs  and  tissues  (lungs,  kid- 
ney, bladder,  prostate,  vesicle,  etc.)  are  attacked,  is  the  removal  of  the 
patient  to  a  suitable  climate  which  is  high,  dry,  and  sunshiny — the 
Adirondacks,  Southern  California,  and  Colorado.  In  all  cases  it  must 
be  remembered  that  climate  is  the  chief  curative  factor,  and  that  the 
action  of  drugs  is  only  secondary.  Benefit,  however,  may  result  from 
the  use  of  cod-liver  oil,  the  hypophosphites,  creasote,  iodide  of  iron,  and 
tonics,  all  of  which  should  be  judiciously  employed.  The  adoption  of 
surgical  measures  depends  wholly  upon  the  extent  and  seat  of  the  tuber- 
cular lesion. 

If  there  are  indurated  masses  in  the  epididymis  or  in  the  testis  these 
points  should  be  incised,  thoroughly  scraped,  and  packed  with  iodoform 
gauze. 

If  there  are  sinuses  leading  into  the  epididymis  or  testis,  they  should 
be  enlarged,  scraped,  and  packed  with  absorbent  gauze  or  iodoform 
ointment. 

When  the  entire  testis  is  extensively  involved  and  broken  down  it 
is  necessary  to  resort  to  castration  ;  but  in  these  cases  the  necessity  of 
climatic  change  should  be  forcibly  impressed  on  the  patient. 

CYSTIC  SARCOMA. 

This  form  of  testicular  tumor  (and  the  parotid  gland  is  sometimes 
similarly  affected)  is  rare,  and  is  found  in  the  proportion  of  about 
three  in  one  hundred  cases  of  malignant  disease  of  the  testis.  It  occurs 
most  frequently  between  the  ages  of  twenty  and  forty,  a  large  number 
of  cases  having  been  noted  between  thirty  and  forty  and  a  smaller  num- 
ber between  twenty  and  thirty.  It  may  occur  in  early  and  in  late  life, 
but  the  cases  of  its  very  late  development  are  quite  rare.     As  a  rule, 


358  AFFECTIONS  OF  THE  TESTIS,   ETC. 

but  one  testis  is  attacked.      It  runs  its  course  to  a  fatal  termination 
in  from  one  to  two  years. 

The  disease  begins  insidiously,  without  marked  subjective  symp- 
toms. As  the  growth  increases,  a  smooth,  hard,  firm,  sometimes 
densely  elastic,  indolent  tumor  is  produced.  Spontaneous  pain  is  not 
present,  and  the  patient  simply  complains  of  a  dragging  sensation  and 
the  impediment  offered  by  the  size  of  the  tumor.  Hydrocele  is  some- 
times a  complication.  Being  smooth,  hard,  and  firm  in  its  commence- 
ment, this  form  of  testicular  degeneration  may  be  diagnosticated  as 
syphilitic,  so  much  does  it  resemble  syphilitic  sarcocele.  But  the 
touchstone  to  the  diagnosis  lies  in  treatment.  It  is  always  well  in 
these  cases,  if  the  history  is  misleading  or  negative,  to  put  the  patient 
under  active  local  and  general  antisyphilitic  treatment.  If  the  dis- 
ease is  of  specific  origin,  the  morbid  process  will  be  arrested  and 
the  swelling  will  gradually  subside.  If  it  is  of  malignant  nature, 
it  will  go  on  increasing  in  spite  of  medication,  and  then  the  surgeon 
knows  that  ablation  is  necessary.  Usually  the  surface  of  the  tumor  in 
its  early  development  is  smooth,  but  sometimes  it  becomes  nodular, 
rugose,  or  bossy  quite  early.  In  this  event  the  suspicion  of  malignancy 
is  warranted.  In  the  course  of  time  the  morbid  growth  becomes  ex- 
uberant and  fungating.     (See  Plate  XIII.) 

Pathology. — The  morbid  structure  of  these  tumors  is  not  generally 
well  understood.  Thorough  microscopical  study  of  a  typical  case 
observed  by  me  developed  the  following  facts : 

The  testicle  was  largely  composed  of  a  congeries  of  variously  sized 
cysts,  the  larger  of  which  measured  one-half  centimetre.  In  places  the 
cysts  were  closely  approximated,  communicating  with  each  other  and 
lined  by  thin  walls. 

The  intimate  structure  was  as  follows  : 

1.  Small  regularly  spherical  acini  lined  with  cylindrical  epithelium. 
These  corresponded    to    the    typical    adenoma    portions  of  the  tumor. 

2.  Very  irregularly  branching  cavities,  lined  with  less  regularly  dis- 
posed columnar  cells.  These  cavities  were  on  the  border-line  of  car- 
cinoma, and  indicated  a  departure  from  the  perfect  adenoma  type,  so 
that  the  tumor  was  really  adenocarcinoma.     (See  Plate  XIII. ,  Fig.  2.) 

3.  Very  large  cavities  lined  with  epithelium  and  frequently  filled 
with  granular  and  fluid  material.  These  represented  cystic  trans- 
formation of  the  adenomatous  portions  of  the  tumor. 

4.  Tiny  islands  of  hyaline  cartilage. 

5.  The  remainder  of  the  tumor  was  composed  of  closely  packed 
small  spindle-shaped  cells  or  tissue  in  various  stages  of  productive 
inflammation.  The  small  spindle-celled  tissue  was  arranged  in  the 
manner  characteristic  of  sarcoma. 


PLATE  Xni. 
Fig.  i. 


fig.  2. 


9g|  •     Sr 


CYSTIC  SARCOMA  OF  TESTIS. 


CYSTIC  SARCOMA.  359 

The  tumor,  then,  was  complex  and  was  composed  of  sarcoma, 
chondroma,  adenoma,  and  cystic  adenocarcinoma. 

Treatment. — When  the  diagnosis  of  cystic  sarcoma  is  definitely 
made,  prompt  removal  of  the  affected  organ  should  be  practised. 

Carcinoma. 

Cancer  of  the  testicle  is  usually  encountered  about  middle  life,  but 
may  occur  much  earlier  or  at  a  later  period.  It  is  the  most  frequent 
of  all  new  growths  of  this  organ,  and  may  be  of  the  medullary  or  the 
scirrhous  type,  the  medullary,  or  soft,  variety  being  the  most  com- 
mon.    As  a  rule,  but  one  testicle  is  involved. 

Its  etiology  is  as  obscure  as  is  that  of  cancer  in  other  glands  or 
organs.  Inflammatory  conditions  and  traumatisms  seem  to  be  predis- 
posing causes. 

Beginning  in  the  testicle  or  the  epididymis,  it  finally  involves  the 
entire  gland,  eventually  extending  up  the  cord  and  invading  the 
inguinal  and  retroperitoneal  glands.  The  testicle  increases  in  size,  and 
is  hard  and  smooth  to  the  touch,  and  the  veins  of  the  scrotum  are 
enlarged  and  tortuous.  The  cord  becomes  thickened  and  indurated. 
Pain  is  usually  slight  or  absent.  As  the  tumor  increases  in  size  it 
becomes  soft  and  almost  fluctuating,  and  adherent  to  the  skin,  through 
which  it  finally  protrudes  as  a  fungating  bleeding  mass.  Unless  proper 
treatment  has  been  employed  at  the  outset  of  the  disease,  the  patient 
finally  dies  from  exhaustion  and  involvement  of  other  organs. 

Treatment. — The  testicle  should  be  removed  as  soon  as  the  diag- 
nosis has  been  made,  and  the  cord  divided  as  far  up  as  possible.  The 
inguinal  glands  are  to  be  removed,  as  well  as  the  scrotal  tissues  on  the 
aifected  side,  even  if  they  appear  perfectly  healthy. 

Sarcoma. 

Sarcoma  of  the  testicle  may  occur  at  almost  any  time  of  life,  but  is 
usually  encountered  in  young  subjects  and  children.  It  may  be  made 
up  of  round  cells,  spindle-cells,  or  both  combined,  and  very  frequently 
a  variety  of  abnormal  tissues  is  present  in  these  cases,  when  they  are 
known  as  mixed  tumors,  or  teratoma.     (See  Cystic  Sarcoma,  p.  357.) 

The  clinical  course  of  the  disease  and  the  treatment  are  the  same 
as  those  given  for  carcinoma. 

Fibroma. 

This  is  a  very  rare  affection  of  the  testicle,  occurring  in  young  adult 
life.  It  forms  a  hard,  painless  tumor,  which  grows  slowly,  shows  no 
tendency  to  extend  up  the  cord  or  to  involve  other  structures. 


360  AFFECTIONS  OF  THE  TESTIS,  ETC. 

Treatment. — The  testicle  should  always  be  removed,  for  fear  of 
possible  malignant  degeneration. 

Enchondroma. 

Cartilaginous  tumor  of  the  testicle  resembles  fibroma  so  closely  that 
the  description  of  the  former,  both  clinically  and  as  to  treatment,  is 
equally  applicable  to  the  latter. 

Dermoid  Cysts. 

These  cysts  are  congenital,  and  resemble  similar  tumors  situated  else- 
where in  the  body.  They  may  contain  cartilage,  hair,  teeth,  bone,  or 
skin,  and  are  situated  either  on  the  surface  or  in  the  body  of  the  gland. 
These  tumors  may  interfere  with  descent  of  the  testicle,  or,  as  a  result 
of  pressure,  they  may  cause  imperfect  development  or  atrophy  of  the 
gland.  At  about  the  time  of  puberty  they  increase  in  size,  thus  mak- 
ing their  presence  known  to  their  bearers. 

Treatment. — These  cysts  should,  if  possible,  be  enucleated  from 
the  testicle,  the  gland  itself  not  being  interfered  with.  This  failing, 
however,  the  testicle  to  a  greater  or  less  extent  will  have  to  be 
removed. 

Cysts  (Cystoma  Testis). 

Scattered  through  the  testicle  in  a  fibrous  tissue  stroma,  or  associated 
with  sarcomatous  or  carcinomatous  tissues,  are  sometimes,  though  rarely, 
found  cysts,  varying  greatly  in  size  and  number,  and  containing  a  clear 
or  brownish  or  even  bloody  fluid.  In  some  cases  their  contents  are 
cheesy  in  consistence. 

Treatment. — The  testicle  should  be  removed  immediately  and  the 
cord  ligated  and  cut  as  high  up  as  possible. 

CASTRATION. 

The  patient  being  properly  prepared  is  placed  on  his  back  and  ether- 
ized, an  incision  is  made  through  the  long  axis  of  the  anterior  scrotal 
wall  down  to  the  tunica  vaginalis,  and  the  whole  organ  is  shelled  out  en 
masse  from  the  surrounding  scrotal  tissues,  as  in  the  radical  operation  for 
hydrocele.  The  tunica  is  opened  and  examined  to  exclude  the  possible  ex- 
istence of  a  hernia,  and  then  the  cord  is  stripped  of  its  serous  covering  as 
high  up  as  possible,  and  it  is  ligated  with  heavy  silk  or  gut.  To  pre- 
vent the  slipping  of  the  ligature,  it  is  best  to  have  it  transfix  the  cord,  and 
then  ligate  each  half  separately  and  then  again  en  masse.  The  cord  is 
then  cut  as  high  as  is  deemed  advisable  and  its  individual  vessels  ligated 
with  gut.  All  bleeding  points  are  caught  and  tied,  the  wound-cavity 
wiped  dry  and  the  wound  itself  closed  with  sutures,  or  its  dependent 


CASTRATION.  361 

part  left  open  for  a  small  rubber  tissue-drain.     The  parts  are  dressed 
with  sterile  gauze  and  supported  in  the  usual  manner. 

The  above  operation  is  performed  in  those  simple  cases  where  the 
disease  is  limited  to  the  testicle,  the  tunica  and  scrotum  not  being  adher- 
ent or  involved.  If,  however,  the  tunica  vaginalis  and  scrotum  are 
adherent  to  the  testicle,  or  the  seat  of  disease,  sinuses,  or  fistula?,  then 
the  incision  must  be  elliptical  in  shape  and  extend  from  the  external 
r'mcr  well  down  to  the  bottom  of  the  scrotum  so  as  to  include  all  such 
infiltrated  and  infected  areas.  The  remainder  of  the  operation  is  per- 
formed as  above  described. 


CHAPTER   XVI. 

AFFECTIONS    OF    THE    SPERMATIC    CORD.1 
VARICOCELE. 

The  term  varicocele  is  used  to  denote  a  varicose  condition  of  the 
spermatic  veins  by  which  a  generalized  or  localized  swelling  in  the 
scrotum  is  produced.  It  is  usually  a  mild  affection,  and  occurs  in  well- 
marked  form  in  about  10  per  cent,  of  all  male  subjects.  Many 
men  have  slight  fulness  and  tortuosity  of  the  spermatic  veins  who 
cannot  be  said  to  have  varicocele. 

This  affection  is,  as  a  rule,  developed  slowly,  insidiously,  and  pain- 
lessly. Again,  it  develops  quite  rapidly  and  with  much  discomfort  to 
the  bearer.  In  the  vast  majority  of  cases  varicocele  is  found  only  on 
the  left  side. 

While  varicocele  may  sometimes  be  found  in  boys  of  twelve  to 
fifteen  years,  it  is  mostly  seen  in  adolescents  and  in  men  up  to  thirty 
years  of  age. 

Etiology. — Various  reasons  are  given  for  the  constancy  of  occur- 
rence of  varicocele  on  the  left  side.  The  main  cause  probably  lies  in  the 
fact  that  the  left  spermatic  vein  empties  at  right  angles  into  the  corre- 
sponding renal  vein.  Further,  the  left  spermatic  vein  may  sometimes 
be  pressed  upon  by  the  sigmoid  flexure,  which  is  posterior  to  it  and  dis- 
tended by  fecal  accumulation.  Whether  our  modern  method  of  "dress- 
ing" has  any  influence  in  causing  enlargement  of  the  veins  of  the  left 
side  of  the  scrotum  is  an  unsettled  question. 

Varicocele  is  sometimes  of  congenital  origin.  Heredity  may  also 
be  an  underlying  cause.  There  can  be  no  doubt  that  vessel-tissue  may, 
like  other  tissues,  be  transmitted  in  a  condition  of  vulnerability.  There 
is  frequently  found  a  coexistence  of  other  vascular  anomalies  with 
varicocele. 

Hernia  and  tumors  in  the  groin,  particularly  when  seated  in  or  near 
the  external  ring,  are  liable  to  press  on  these  veins  and  produce  vari- 
cocele. Various  other  causes  have  been  believed  to  induce  this  condi- 
tion. For  instance,  it  is  stated  by  some  authors  that  ungratified  sexual 
desire  and  excessive  venery  are  important  factors  in  its  cause.  My 
opinion  is,  that  as  predisposing  causes  these  perhaps  may  be  con- 
sidered as   somewhat  influential,  since   any  condition    which    tends    to 

1  See  also  Deferentitis  and  Funiculitis,  page  114. 
362 


VARICOCELE.  363 

induce  engorgement  of  the  spermatic  vessels  is  liable  to  aggravate 
this  condition,  and  perhaps  even  to  lead  to  its  development.  There  is 
no  scientific  evidence  whatever  in  support  of  the  statement  frequently 
made,  that  masturbation  causes  varicocele.  On  the  contrary,  the  latter, 
by  its  irritating  influence,  may  lead  to  the  practice  of  masturbation.  I 
have  frequently  seen  the  mild  congestion  of  the  spermatic  veins  of 
continent  young  men  speedily  pass  away  after  marriage.  Varicocele 
very  often  occasions  more  or  less  mental  suffering  in  patients  afflicted 
with  it.  Some  patients,  like  many  surgeons,  regard  it  as  the  result 
of  masturbation  practised  in  early  years,  and  fear  that  it  will  lead  to 
irnpotency;  while  in  others,  again,  its  existence  causes  the  most  gloomy 
thoughts,  which  sometimes  result  in  well-marked  hypochondriasis. 

Varieties. — The  following  forms  of  varicocele  may  be  found : 

There  is,  first,  the  elongated,  diffused  swelling,  which  extends  from 
the  external  abdominal  ring  down  to  the  testicle,  which  is  larger  high 
up  than  lower  down  ; 

The  second  form  is  that  of  a  diffuse  tumor  surrounding  the  testicle, 
particularly  its  upper  part,  and  extending  halfway  up  to  the  external 
abdominal  ring ; 

The  third  form  is  a  goodly  sized  tumor  just  below  the  external  ring 
and  extending  halfway  down  to  the  testis. 

When  a  varicocele  tumor  is  palpated,  a  sensation  is  conveyed  to  the 
fingers  like  that  of  a  mass  of  earth-worms,  and  this  simile  is  sometimes 
rendered  all  the  more  striking  by  the  contraction  of  the  cremaster 
muscle.  Very  often  the  scrotum  is  lax  and  dependent,  and  in  its  walls 
tortuous,  flaccid  veins  can  be  distinctly  seen.  Under  the  influence  of 
cold  the  scrotum  and  its  varicocele  contract  materially,  while  heat 
and  excitation  tend  to  produce  marked  laxity  and  elongation  of  the 
parts. 

Symptoms. — The  symptoms  of  varicocele  depend  largely  upon  the 
size  and  condition  of  the  tumor.  When  it  is  large,  long,  and  dependent, 
the  patient  often  complains  of  a  sensation  of  weight,  dragging,  and 
of  mild  tension,  which  may  extend  to  the  groin,  loins,  and  even  to 
the  lumbar  region.  All  these  symptoms  may  be  aggravated  by  exces- 
sive heat  and  overexertion.  In  other  cases  patients  suffer  from  a  dull, 
aching  pain,  which  has  periods  of  intensity  and  intermission.  Acrampy 
pain  is  sometimes  complained  of  in  cases  in  which  the  tumor  is  very 
large.  In  all  probability  this  pain  is  due  to  the  tense  condition  of 
the  cremaster  muscle.  The  sharp  pain  sometimes  complained  of  is,  in 
all  probability,  due  to  spasm  of  the  cremaster  muscle  associated  with 
intra-abdominal  pressure.  Tenderness  of  the  veins  and  of  the  cord  is  a 
not  infrequent  symptom,  particularly  in  nervous,  neurasthenic,  and 
overanxious    patients.     Very    often  patients    themselves   produce    this 


364  AFFECTIONS  OF  THE  SPERMATIC  CORD. 

symptom  by  repeated  manipulation  of  their  varicocele.  Heat,  over- 
exertion, jolting,  and  bicycling  also  excite  this  symptom  temporarily. 
In  many  cases  there  are  no  symptoms  whatever. 

Varicocele  consists  in  excessive  development  of  the  veins,  the  walls 
of  which  become  thickened  by  cell-increase,  and  ■  are  subsequently  the 
seat  of  fatty  change,  and,  in  some  cases,  even  of  calcareous  degeneration. 
Phlebolites  are  sometimes  found  within  the  veins,  while  in  general  their 
valves  are  wholly  eifaced  and  their  walls  much  thinned.  Certain  sec- 
ondary changes  in  parts  in  connection  with  the  spermatic  veins  often 
follow  varicocele.  For  example,  as  a  result  of  the  weight  of  the 
venous  tumor  the  scrotum  sometimes  becomes  more  or  less  redun- 
dant and  relaxed  and  its  walls  much  thinned.  In  such  instances  the 
power  of  the  dartos  muscle  is  more  or  less  impaired.  Further,  in 
chronic  cases  a  softened  condition,  with  perhaps  slight  atrophy  of  the 
testis,  is  a  not  uncommon  sequela  ;  while  early  in  the  course  of  varico- 
cele it  is  not  unusual  to  find  a  slightly  congested  condition  of  this  organ, 
due,  of  course,  to  the  impediment  to  the  return  circulation.  As  a  result 
of  these  changes,  it  often  happens  that  ultimately  the  testicle  grows  grad- 
ually smaller,  until  in  some  cases  it  is  reduced  to  the  size  of  a  pea  and 
sometimes  it  seems  to  be  wholly  absorbed.  Hydrocele  is  another  not 
infrequent  complication,  but  it  is  always  of  a  subacute  character  and 
usually  not  very  extensive.  Thrombus  of  the  veins  is  an  occasional 
complication. 

Patients  sometimes  attribute  want  of  sexual  power,  due  to  other 
causes,  to  varicocele,  and  therefore  demand  relief.  So  importunate  are 
some  of  them,  and  so  deaf  to  reasoning,  that  the  surgeon  is  forced  to 
perform  the  operation  for  its  mental  effect.  This  condition  of  mind  is 
mostly  found  in  men  beyond  forty  years  of  age. 

Diagnosis. — The  diagnosis  offers  no  difficulties  whatever,  since  simple 
inspection  presents  a  striking  clinical  picture,  and  palpation  reveals  the 
worm-like  mass  within  the  scrotum.  If  the  external  abdominal  ring  is 
now  compressed  with  the  finger-tips  and  the  patient  told  to  stand  up, 
the  veins  will  be  felt  to  be  empty ;  then,  withdrawing  the  pressure  of 
the  finger-tip,  the  sudden  filling  of  the  veins  can  be  readily  felt.  A 
hernia  when  reduced  may  stay  up ;  if  it  should  come  down,  it  forms  a 
cylinder  of  decided  calibre,  which  gives  an  entirely  different  sensation 
from  that  offered  by  veins  filling  with  blood. 

Treatment. — Palliative  treatment  may  be  of  benefit  in  some  cases. 
Much  relief  can  be  afforded  by  the  use  of  cold  douches  and  by  attention 
to  the  condition  of  the  bowels.  Patients  in  a  neurotic  or  neurasthenic 
condition  should  be  treated  symptomatically.  Errors  in  sexual  hygiene 
should  be  corrected,  according  to  the  indications  in  each  case.  Since 
physical  exhaustion  of  any  kind  tends  to  aggravate  varicocele,  patients 


VARICOCELE.  365 

should  be  put  on  their  guard  in  this  direction.  When  an  opera- 
tion is  not  admissible,  much  comfort  is  afforded  patients  by  the  use 
of  a  snugly-fitting  and  well-supporting  suspensory.  The  surgeon 
should  take  pains  to  see  that  the  bandage  is  suited  to  each  case,  since 
discomfort  may  be  felt  by  a  patient  who  indiscriminately  purchases  and 
wears  a  suspensory. 

The  radical  cure  of  varicocele  can  be  effected  by  a  number  of  sur- 
gical procedures,  many  of  which  are  complicated  and  attended  with 
difficult  after-treatment,  and  need  not  be  mentioned. 

The  ideal  operation  for  varicocele  is  the  open  one.  The  results  of 
this  operation  are  uniformly  good.  The  parts  are  -so  clearly  exposed, 
the  ligatures  can  be  applied  with  such  precision,  and  the  operation  is 
so  simple  that  it  cannot  be  commended  too  highly. 

It  is  necessary  to  remember  that  the  veins  to  be  excised  are  those 
of  the  pampiniform  plexus,  which  is  surrounded  by  a  well-defined  con- 
nective-tissue sheath.  These  spermatic  veins  lie  well  in  front,  while 
the  vas  deferens  with  its  artery  and  veins  is  farther  backward  and  in- 
ward in  the  scrotum.  If  the  testis  is  carefully  pulled  downward,  the 
vas  is  put  on  the  stretch,  and  it  can  be  easily  felt,  it  being  hard  and  firm 
like  a  whip-cord.  The  vas  and  the  deferential  artery  and  veins  should 
be  carefully  avoided.  Only  by  gross  carelessness  will  they  be  included 
in  the  ligation  of  the  veins.  In  that  event  there  may  be  sloughing  of 
the  testicle  from  want  of  blood-supply. 

The  Open  Operation. — The  patient  is  properly  prepared  for  the 
operation  and  placed  under  the  influence  of  ether,  or  the  parts  may  be 
freely  cocainized.  An  assistant  holds  the  testicle  firmly  and  draws 
it  horizontally  downward  between  the  thighs.  The  parts  are  then  tense, 
the  veins  can  be  distinctly  felt,  and  under  them  the  vas  is  very  percepti- 
ble. An  incision  is  then  made  for  an  inch  and  a  half  in  the  longitudinal 
direction  and  over  the  prominence  of  the  veins.  The  edges  of  the 
wound  are  separated  by  retractors,  and  the  coverings  of  the  cord 
are  carefully  dissected  until  the  sheath  of  the  veins  comes  into  view. 
It  presents  a  shining,  whitish-gray  color,  through  which  the  purple 
veins  are  seen.  This  sheath  of  the  pampiniform  plexus,  which  must 
not  be  cut  into,  is  then  isolated  by  the  knife,  aided  by  the  fingers,  and 
then  the  ligatures,  of  strong  silk,  are  to  be  applied  by  means  of  an 
eyed  probe  or  aneurysm-needle  about  an  inch  and  a  half  apart.  In  some 
cases  a  longer  incision  is  necessary.  The  lower  ligature  is  tied  first,  and 
then  the  upper  one,  the  ends  being  left  fully  three  inches  long.  The  ves- 
sels are  then  cut  with  scissors  about  a  quarter  of  an  inch  from  the  liga- 
tures. The  cut  ends  of  the  vein  stumps  are  then  brought  together  by 
knotting  the  ends  of  the  upper  ligature  with  those  of  the  lower  and 
cut  off  short.     In  this  way  the  testis  is  drawn  up  to  its  natural  position. 


366  AFFECTIONS  OF   THE  SPERMATIC  CORD. 

The  wound  is  put  on  the  stretch,  so  as  to  bring  the  edges  of  the 
scrotum  in  coaptation.  This  can  be  done  with  the  fingers  or  by  means 
of  blunt  hooks,  one  at  each  end  of  the  wound.  Two,  or  perhaps 
more,  catgut  sutures  are  now  applied,  thus  firmly  fixing  the  parts. 
A  small  opening  in  the  dependent  part  of  the  wound  is  left  for  drain- 
age.    Usually  no  drainage-tube  is  necessary. 

After  the  operation,  the  wound  is  dusted  with  antinosin  or  aristol 
and  dressed  with  sterilized  cotton  and  gauze.  The  first  dressing  may 
remain  on  for  several  days.  Healing  usually  occurs  in  about  a  week  or 
ten  days.  At  first  a  callous  mass  will  be  felt  at  the  point  of  juncture  of 
the  ends  of  the  veins.  This  will  gradually  be  absorbed,  and  in  the 
end  a  little  firm  nodule  will  be  felt.  It  is  well  to  direct  the  patient 
to  wear  a  suspensory  bandage  for  a  short  time  after  any  of  the  radical 
operations  for  varicocele. 

Subcutaneous  ligation  of  the  spermatic  veins  is,  in  these  days  of  ad- 
vanced surgery,  practically  an  obsolete  operation. 

Use  of  the  Electrothermic  Angiotribe  in  lieu  of  the  Em- 
ployment of  Ligatures  in  the  Open  Operation  for  Varico- 
cele.— According  to  Horwitz,  the  use  of  the  electrothermic  angiotribe 
in  the  open  operation  for  varicocele  is  an  ideal  method  of  dealing  with 
conditions  of  the  kind,  removing,  as  it  does,  the  only  objection  that  can 
be  urged  against  the  open  operation — that  is,  the  occasional  infection  of 
the  ligature. 

The  dilated  plexus  of  veins  is  exposed,  separated  from  the  vas 
deferens,  and  folded  into  a  loop  so  as  to  shorten  the  cord  to  the  desired 
extent.  The  base  of  the  loop  is  grasped  by  the  angiotribe,  the  part 
compressed,  and  the  current  allowed  to  pass  for  forty  seconds ;  the  bat- 
tery is  then  disconnected  and  the  loop  above  the  jaws  of  the  instrument 
is  cut  off. 

On  releasing  the  angiotribe  the  stumps  resulting  from  the  resection 
are  found  to  be  ribbon-shaped  and  firmly  adherent,  doing  away  with 
the  necessity  for  the  employment  of  sutures,  which  hitherto  had  always 
been  necessary  in  order  to  unite  the  proximal  and  distal  extremities. 
The  incision  is  closed  by  means  of  two  silkworm-gut  sutures.  The 
patient  usually  leaves  the  hospital  on  the  eighth  day  after  operation. 

Horwitz  employed  the  instrument  devised  by  Downes,  and  claims  for 
it  the  following  advantages  over  the  simple  angiotribe  suggested  by 
Freeman  :  a  more  scientific,  less  crude  and  less  dangerous  method  than 
that  depending  on  violent  traumatism  in  order  to  produce  hsemostasis  is 
substituted;  there  is  less  danger  of  secondary  hemorrhage,  and  from 
thrombus ;  the  operation  is  not  followed  by  pain  ;  the  instrument  is  not 
conducive  to  the  production  of  orchitis,  a  condition  commonly  attending 
operations  in  the  vicinity  of  the  cord. 


VARICOCELE.  367 

Suprapubic  Operation  for  Varicocele. — Under  this  title 
Thornburgh  has  recently  described  an  operation  for  varicocele,  which 
he  claims  affords  a  radical  cure.  The  advantages  of  the  suprapubic  route 
are :  The  field  of  operation  can  readily  be  rendered  aseptic ;  a  dressing 
once  properly  applied  will  remain  indefinitely,  and  will  not  be  affected 
by  the  movements  of  the  patient ;  primary  union  is  a  practical  certainty. 
The  parts  being  rendered  surgically  clean,  the  finger  of  the  operator  is 
introduced  to  the  external  ring,  and  a  nick  made  with  the  knife  directly 
over  the  tip  of  the  finger.  AVith  this  nick  as  a  landmark  an  incision  3 
cm.  long  is  made,  parallel  to  Poupart's  ligament.  The  deep  fascia  is 
cut  through  with  the  knife,  and  then  a  little  blunt  dissection  brings  the 
cord  into  view.  No  bloodvessels  of  any  moment  are  encountered,  oozing 
being  checked  by  hot  normal  salt  solution.  The  sheath  of  the  cord  is 
picked  up  between  mouse-tooth  forceps  and  torn  open.  The  finger  of  the 
operator  is  introduced,  and  the  whole  cord  easily  raised  from  its  bed  and 
brought  out  of  the  wound  ;  a  ligature-carrier  is  then  placed  beneath  it. 
The  vas  is  recognized  by  its  white  appearance  and  cord-like  feel,  and  is 
separated  from  the  rest  of  the  cord  downward  to  within  an  inch  of  the 
testis.  The  testis  can  readily  be  brought  into  view  by  gentle  traction  on 
the  cord.  The  vas  is  separated  from  the  vessels  for  about  6  or  7  cm.  in 
an  upward  direction  also.  The  vessels  are  tied  with  No.  3  cumolized 
catgut  ligatures,  the  vessels  between  them  (5  to  6  cm.)  excised,  the  stumps 
inspected  for  oozing,  the  ends  approximated,  and  the  ligatures  tied  to 
each  other,  thus  forming  a  support  for  the  testis.  It  is  unnecessary  to 
isolate  and  save  the  spermatic  artery  and  a  vein.  At  the  end  of  twelve 
days  the  dressings  may  be  removed,  and  in  three  or  four  days  more  the 
patient  may  return  to  his  usual  occupation.  A  suspensory  should  be 
worn  for  at  least  six  weeks  following  the  operation. 

My  criticism  on  this  method  is  this  :  That  a  rather  severe  operation, 
namely,  the  opening  of  the  inguinal  canal,  is  substituted  for  the  simple 
incision  through  the  scrotum. 

Ablation  of  the  Scrotum. — Formerly,  in  cases  in  which  the 
scrotum  was  flabby  and  redundant  concomitantly  with  varicocele,  some 
surgeons  attempted  to  afford  relief  by  ablation  of  that  portion  which 
was  excessive.  The  drawback  to  the  operation  was  that  in  many 
cases  the  redundance  of  tissue  reappeared  as  a  result  of  the  sagging 
of  the  varicose  tumor.  Owing  to  the  simplicity  and  success  of  the 
open  operation  ablation  of  the  scrotum  is  now  rarely,  if  ever,  necessary. 
If,  however,  the  operation  be  decided  upon,  it  should  be  performed  on 
general  surgical  lines,  a  scrotal  clamp  being  used  to  hold  the  tissues 
in  situ  and  to  guide  the  line  of  incision. 


CHAPTER   XVII. 

AFFECTIONS    OF    THE    SEMINAL    VESICLES.1 

Anomalous  conditions  of  the  seminal  vesicles  occur  so  rarely  that 
they  are  to  be  regarded  merely  as  medical  curiosities,  and  are  therefore 
not  described  at  length.  The  vesicles  may  be  cut  or  injured  during 
surgical  operations  or  in  general  injuries,  especially  of  and  about  the 
pelvis. 

As  a  result  of  plugging  of  the  ejaculatory  duct,  the  vesicle  may  be 
converted  into  a  cyst-like  swelling,  or  tumor,  which  can  be  felt  by 
rectal  touch  projecting  upward  above  the  prostate.  Cases  have  been 
reported  in  which  the  tumor  was  of  enormous  size,  holding  a  pint  or 
more  of  fluid.  These  swellings  may  be  aspirated,  or,  better,  drained  or 
excised  through  the  perineum. 

Malignant  disease  of  the  seminal  vesicle  never  occurs  alone,  being 
associated  with  similar  conditions  in  the  adjacent  structures,  and  is 
therefore  not  described. 

TUBERCULOSIS. 

Tuberculosis  of  the  seminal  vesicle  is  usually  associated  with  a 
similar  process  in  the  testicle,  prostate,  deep  urethra,  or  bladder,  to 
which  it  is  in  the  vast  majority  of  cases  secondary,  although,  of  course, 
it  may  be  attacked  primarily  by  the  tubercular  process. 

Symptoms. — There  may  be  more  or  less  increased  frequency  in 
urination,  with  post-mictional  hematuria.  The  sexual  desire,  which  is 
at  first  increased,  finally  becomes  diminished,  and,  toward  the  end, 
extinct.  Some  patients  suffer  from  painful  nocturnal  pollutions,  which 
are  more  or  less  stained  with  blood.  There  may  be  a  mucoid  dis- 
charge from  the  meatus.  All  of  the  above  symptoms  vary  greatly  in 
different  cases,  depending  upon  the  degree  of  involvement  of  the  ad- 
jacent structures. 

Diagnosis  is  readily  arrived  at  from  the  patient's  previous  history, 
both  personal  and  family,  together  with  his  present  condition,  and  an 
examination  of  the  vesicles  by  rectal  touch.  The  vesicle  feels  like  a 
distended,  irregular  sac  or  pouch  running  upward  and  outward  from 
the  base  of  the  prostate ;  smooth  and  soft  in  some,  and  firm  and  nodu- 
lated in  others,  depending  somewhat  upon  the  stage  of  the  disease. 
Pressure  on  the  vesicle  causes  pain  in  some  cases,  while  in  others  the 
1See  Sections  on  Acute  and  Chronic  Inflammation  of  the  Seminal  Vesicles,  pp.  104  et  seq. 
368 


TUBERCULOSIS.  369 

tumor  is  practically  insensitive.  If  during  the  rectal  exploration  any 
secretion  escapes  from  the  meatus,  it  should  be  examined  for  tubercle 
bacilli,  as  should  also  the  urine,  especially  that  passed  immediately  after 
examination. 

Treatment. — In  the  vast  majority  of  cases,  operative  treatment  is 
not  to  be  thought  of  unless  suppuration  has  occurred  in  the  sac,  when 
its  contents  must  be  evacuated  through  a  perineal  incision,  the  cavity 
cleaned  and  packed  with  iodoform  gauze.  These  patients  should  be 
sent  to  a  suitable  climate  and  receive  the  regular  treatment  for  tuber- 
culous subjects. 

If  it  can  be  ascertained  beyond  doubt  that  the  seminal  vesicle  alone 
is  affected,  as  it  rarely  if  ever  is,  the  surgeon  may  advise  its  removal  by 
the  perineal  route,  employing  either  the  Bydygier,  Zuckerkandl,  or 
von  Dittel  incision ;  in  any  of  these  operations  great  care  should  be 
exercised  not  to  wound  either  the  urethra  or  rectum,  the  former  being 
made  prominent  by  a  bougie,  and  the  latter  by  a  gauze  packing. 

24 


CHAPTER   XVIII. 

AFFECTIONS    OF    THE    BLADDER. 
CYSTITIS. 

Cystitis  is  a  suppurative  inflammation  of  the  bladder,  caused  in 
the  vast  majority  of  cases,  if  not  in  all,  by  microbic  infection  in  a 
bladder  made  vulnerable  or  susceptible  from  congestion  of  its  mucous 
membrane. 

For  clinical  and  therapeutic  purposes,  it  is  best  to  divide  cystitis  into 
two  stages,  viz.,  acute  and  chronic,  according  to  the  duration  of  the 
attack  and  the  severity  of  its  manifestations.  The  mucous  membrane 
of  the  prostatic  urethra  and  that  of  the  trigone  and  about  the  ureteral 
orifices  are  always  most  intensely  involved  in  the  inflammatory  pro- 
cess, which,  beginning  in  the  mucous  membrane  about  these  regions, 
may  in  untreated  or  neglected  cases  finally  involve  the  muscular  and 
even  the  serous  coats  of  the  bladder. 

Etiology. — The  most  frequent  pathologic  agent  in  cystitis  is  the 
colon  bacillus  (Bacterium  coli  commune) ;  next  in  order  is  found  the 
Streptococcus  pyogenes.  Cystitis  due  to  these  microbes  may  present 
varying  clinical  phases,  but  the  urine  is  usually  fetid  in  odor  and 
acid  in  reaction.  Upon  long  standing  outside  the  body  or  in  cases 
of  retention  with  overflow  and  residual  urine  the  Bacterium  coli  com- 
mune may  produce  decomposition  of  urea,  with  the  liberation  of  car- 
bonate of  ammonium,  which  coagulates  the  pus  into  gelatinous,  ropy 
masses  and  gives  the  urine  its  alkaline  reaction  and  ammoniacal 
odor  (ammoniuria).  This  decomposition  is  always  secondary  to  cystitis, 
and  is  never  the  cause  of  the  bladder  inflammation.  All  pyogenic  organ- 
isms apparently  have  the  power  of  decomposing  urea,  with  like 
results. 

The  most  dangerous  microbe  is  the  proteus  of  Hauser.  This 
bacterium  exerts  an  energetic  action  in  the  decomposition  of  the 
urea,  and,  by  means  of  the  ammonia  which  it  produces,  may  excite  in- 
flammation in  a  perfectly  healthy  bladder.  In  other  words,  without 
any  tissue-predisposition,  this  microbe  may  cause  cystitis  by  reason  of 
the  chemical  irritant  (ammonia)  which  it  produces  in  urine.  Although 
the  Staphylococcus  ureas  liquefaciens  has  been  found  in  purulent  am- 
moniacal urine,  yet  the  exact  causative  relation  of  the  microbe  to  cys- 
titis  has    not    been    positively  demonstrated.     These    two    microbes, 

370 


CYSTITIS.  371 

together  with  the  Streptobacillus  anfhraeoides,  certainly  are  pathologic 
to  bladder-tissues,  but  further  observations  are  necessary  to  clear  up  the 
doubt  as  to  their  being  the  primary  agents  of  infection. 

Although  the  genitals  of  both  males  and  females  swarm  with 
microbes,  innocent  and  pathogenic,  it  is  interesting  to  learn  that  by  care- 
ful culture  Melchoir  found  the  Bacterium  coli  commune  and  the 
Staphylococcus  pyogenes  aureus  upon  the  prepuce,  in  the  vulva  and 
vagina,  and  upon  the  lips  of  the  meatus  in  both.  When  to  this 
knowledge  is  added  the  well-demonstrated  fact  that  in  the  normal, 
and  particularly  in  the  diseased,  urethra  several  forms  of  pathologic 
microbes  are  constantly  present,  it  can  readily  be  seen  how  easy  it  is  to 
excite  inflammation  by  the  conveyance  of  these  micro-organisms  into  a 
susceptible  bladder  by  means  of  instruments. 

Infection  may  travel  backward  from  the  urethra  or  prostate,  or 
downward  from  the  kidney  or  ureter,  and  also  directly  from  the  rectum, 
especially  in  the  chronically  constipated  subject  who  suffers  from  hemor- 
rhoids and  whose  prostate  gland  is  more  or  less  congested  and  diseased. 
The  rough  passage  of  sterile  instruments  may  cause  cystitis  by  the 
lighting  into  activity  of  microbes  present  in  both  the  normal  and  dis- 
eased urethra. 

Pyogenic  microbes  can  be  introduced  into  the  healthy  bladder  with 
impunity  provided  there  is  no  congestion  of  its  mucous  membrane  and 
that  the  instrument  causes  none  (traumatism).  It  must  be  borne  in 
mind  that  normal  urine  in  a  normal  bladder  is  absolutely  sterile.  The 
healthy  mucous  membrane  has  the  power  to  resist  micro-organisms, 
which  power  is  lessened  and  finally  lost  by  congestion. 

Gonorrheal  cystitis  is  in  reality  a  mixed  infection,  in  which  the  gono- 
coccus  plays  a  very  insignificant  part,  the  micro-organisms  of  other 
forms  of  cystitis  outnumbering  the  gonococcus  greatly. 

In  tubercular  cystitis,  the  tubercular  deposit  or  process  first  causes 
the  necessary  congestion  of  the  vesical  mucous  membrane,  which  in 
time  is  followed  by  a  true  purulent  cystitis  ;  in  other  words,  the  tubercle 
bacillus  antedates  the  advent  of  the  pus  micro-organism,  for  which  it 
prepares  a  suitable  soil. 

The  so-called  catheter,  calculus,  tumor,  prostatic,  and  stricture  cys- 
tites  are  all  in  reality  the  same  process,  having  different  etiological 
factors,  and  therefore  do  not  require  to  be  considered  separately. 

The  vesical  congestion  which  is  requisite,  and  prepares  a  suitable 
soil  or  culture-ground  for  microbic  infection,  may  be  caused  by  anything 
that  retards  or  stops  the  free  outflow  of  urine  or  that  causes  local  irrita- 
tion and  congestion  of  the  mucous  membrane,  as,  for  example  : 

Retention  of  urine,  either  partial  or  complete,  from  urethral  strict- 
ure, prostatic  disease,  compressor  spasm,  or  paralysis  of    the  bladder 


372  AFFECTIONS  OF  THE  BLADDER.      * 

musculature,  is  invariably  followed  by  more  or  less  congestion  of  the 
bladder  mucous  membrane,  which  also  results  from  the  traumatism  of 
calculi,  rough  instrumentation,  foreign  bodies,  tumors,  irritating  irri- 
gations, and  overdistention  of  the  bladder  by  too  copious  lavage. 

Catching  cold,  chilling  of  the  surface  of  the  body,  gout,  rheumatism, 
irritating  urine,  etc.,  may  give  rise  to  a  transient  vesical  congestion,  but 
do  not  of  themselves  cause  true  cystitis,  unless  there  is  a  subsequent 
germ  infection  or  an  already  existing  congestion  due  to  an  old  posterior 
urethritis,  urethrocystitis,  stricture  of  the  urethra,  or  prostatic  disease, 
which  is  lighted  into  activity  by  the  acute  congestion  of  the  vessels. 

Long-continued  ungratified  sexual  excitement,  sexual  excesses,  and 
masturbation  cause  congestion  of  the  prostate  and  the  deep  urethra, 
thus  preparing  a  suitable  soil  for  infection  (cystitis)  from  any  of  the 
above-mentioned  causes. 

Pathology. — The  acute  or  superficial  variety  of  cystitis,  beginning 
in  and  limited  to  the  mucous  coat,  causes  congestion  and  dilatation 
of  the  bloodvessels  and  a  hypersemic  and  oedematous  condition  of  the 
mucous  membrane  in  the  region  of  the  trigone,  which  in  time  may  in- 
volve more  or  less  of  the  bladder  surface.  The  urine  at  this  time  is 
acid  in  reaction,  and  cloudy  and  opaque  from  pus,  epithelium,  and  tis- 
sue-elements. 

As  the  process  passes  into  the  chronic  stage  the  mucous  membrane 
assumes  a  yellowish-pink  or  gray  hue,  and  its  surface  is  seen  to  be 
thrown  into  folds  or  projections  (trabeculse)  which  are  in  reality  due  to 
hypertrophy  of  the  bladder  muscles,  caused  by  the  increased  amount 
of  work  which  they  were  called  upon  to  perform  during  the  acute 
stage.  Enlarged  vessels  can  now  be  seen  coursing  beneath  the  sur- 
face, to  which  may  cling  shreds  of  muco-pus,  encrusted  in  some  in- 
stances with  urinary  salts. 

The  urine  is  thick  and  purulent  and  filled  with  heavy  clumps  and 
shreds  of  tissue.  Its  reaction  is  alkaline  and  its  odor  often  ammoniacal 
from  the  decomposition  of  the  urea  by  the  micro-organisms,  with 
liberation  of  carbonate  of  ammonium,  which  changes  the  pus  into  clumps 
or  masses  of  gelatinous  material.  A  thick  sediment  is  soon  deposited 
on  standing.  If  the  disease  progresses  unchecked,  it  finally  invades 
the  submucous  connective-tissue  layer  and  muscular  coat,  constituting 
true  interstitial  cystitis,  in  which  form  both  of  the  layers  become 
infiltrated  and  thickened,  and  in  some  cases  the  seat  of  small  pus 
foci  or  abscesses,  which  may  rupture  either  into  the  bladder  cavity 
or  the  perivesical  tissues  and  structures,  causing  a  pericystitis. 

Under  the  heading  of  membranous,  desquamative,  or  exfoliative 
cystitis  is  described  a  condition  in  which  a  more  or  less  complete  hollow 
cast  of  the  bladder  is  voided  with  the  urine  or   removed  by  operation, 


CYSTITIS.  373 

the  membranous  castor  mould  being  made  up  of  bladder  epithelium  held 
together  by  a  fibrinous  material. 

Symptoms. — The  symptoms  of  cystitis  are  liable  to  great  variations, 
depending  somewhat  upon  the  etiology  of  the  disease  and  whether  it  is 
acute  or  chronic  in  character. 

In  acute  cystitis  the  urine  is  acid  in  reaction,  and  turbid  from  the 
presence  of  pus,  mucus,  and  epithelium.  In  severe  and  very  acute 
cases  there  is  an  admixture  of  blood  from  the  congested  mucous  mem- 
brane of  the  vesical  neck  and  trigonum.  In  most  cases  there  is  a 
marked  increase  in  frequency  of  urination,  with  inability  to  hold  the 
urine  when  the  desire  comes  on,  which  becomes  so  marked  in  some  that 
the  patient  has  practically  incontinence,  the  desire  to  empty  the  bladder 
of  its  contents  being  almost  constant,  and  followed  by  severe  pain  and 
tenesmus  and  a  few  drops  of  blood-stained  and  thickly  purulent  urine. 
The  intense  irritation  about  the  vesical  neck  now  causes  spasm  of  the 
compressor  or  bladder  muscles,  which,  suddenly  closing  the  urethra  or 
causing  violent  bladder  cramps,  adds  greatly  to  the  patient's  suffering, 
which  at  this  period  is  most  distressing,  as  he  suffers  constantly  from 
suprapubic  pain  and  tenesmus,  with  more  or  less  inability  to  void 
the  bladder  of  its  irritating  contents.  These  patients  usually  become 
very  sick,  having  more  or  less  fever  with  a  high-tensioned  pulse,  dry 
and  coated  tongue,  great  thirst,  loss  of  appetite,  with  nausea  and  per- 
haps vomiting.  It  is  at  this  time  that  infection  is  liable  to  extend 
to  the  kidney  by  way  of  the  ureters. 

If  stone,  tumor,  foreign  body,  prostatic  disease,  or  tight  stricture 
complicates  the  case,  all  of  the  above  symptoms  will  be  much  more 
marked  in  character. 

As  the  inflammation  passes  into  the  chronic  stage,  the  urine,  which 
was  at  first  acid,  becomes  neutral  and  finally  alkaline  in  reaction,  with 
an  ammoniacal  odor.  It  now  contains  pus,  blood,  micro-organisms, 
and  vesical  and  prostatic  epithelium,  together  with  triple  phosphates, 
which  conditions,  if  not  corrected,  are  very  liable  to  lead  to  stone 
formation,  especially  in  prostatics  with  a  deep  post-trigonal  pouch, 
and  in  cases  of  trabeculated  and  sacculated  bladders  the  result  of 
an  intense  and  prolonged  cystitis  with  obstruction  to  urination.  All 
of  the  acute  symptoms  now  become  much  less  marked.  The  patient 
still  has  frequent  urination,  but  he  has  more  ability  to  hold  the  urine 
after  the  desire  is  felt.  Tenesmus  is  mild  or  absent,  and  the  constant 
acute  and  deep-seated  pain  over  the  bladder  and  in  the  pelvis  is  changed 
to  a  dull  or  dragging  sensation  ;  in  other  words,  an  acute  process  has 
been  converted  into  a  chronic  one,  which  latter  is  liable  to  be  lighted  up 
by  the  slightest  indiscretion  on  the  part  of  the  patient,  or  by  too  zealous 
examination  and  treatment  on  the  part  of  the  surgeon. 


374  AFFECTIONS   OF  THE  BLADDEE, 

Prognosis. — The  prognosis  of  cystitis  depends  upon  the  age  of  the 
patient,  the  cause  of  the  attack,  whether  it  is  acute  or  chronic,  and  the 
kind  and  degree  of  obstruction  to  urination ;  also  the  condition  of  the 
bladder  walls  and  musculature,  and  whether  or  not  the  kidneys  have 
been  attacked  by  an  ascending  infection  from  the  bladder  along  the 
ureters.  In  young  patients,  therefore,  with  little  or  no  obstruction  and 
healthy  kidneys,  the  prognosis  in  the  vast  majority  of  cases  is  good  ; 
while  in  older  subjects,  with  damaged  kidneys,  trabeculated  and  weak- 
ened bladders,  and  marked  impediment  and  obstruction  to  urination, 
the  prognosis  is  always  grave,  although  even  in  these  severe  cases,  with 
improved  technic  for  vesical  irrigation,  prostatic  operation,  and  urinary 
antisepsis,  both  by  internal  and  local  medication,  we  are  enabled  to  hold 
out  more  hope  than  formerly. 

Treatment. — The  treatment  of  cystitis  depends  upon  the  acuteness 
and  intensity  of  the  attack,  the  condition  and  reaction  of  the  urine,  and 
wmether  it  is  due  to  simple  extension  of  an  inflammatory  process,  a 
tubercular  deposit,  calculous  disease,  foreign  body,  or  some  form  of  ob- 
struction to  the  free  outflow  of  urine.  In  every  case  of  cystitis  the 
surgeon  must  first  ascertain  the  cause  and  either  remove  it,  or,  if  that 
is  contraindicated  at  the  time,  he  should  treat  it  palliatively  according 
to  its  nature.  The  condition  of  the  kidneys  must  be  ascertained  by 
urinary  analysis,  and  abnormal  conditions  treated  on  general  medical 
or  surgical  principles. 

In  the  acute  stage  of  the  disease  the  patient  should  be  put  to  bed,  and 
should  be  kept  there  until  the  subsidence  of  all  acute  symptoms. 
The  diet  consists  of  milk,  weak  tea,  bland  table-waters  in  not  too 
large  quantity,  cereals  with  milk  or  cream,  eggs,  and  breadstuff's, 
breast  of  poultry,  plain  soups  and  broths,  a  little  fish,  oysters,  etc. ;  in 
short,  a  light,  nutritious,  and  easily  digested  diet,  avoiding  all  red  meats 
and  green  vegetables,  and  anything  that  is  highly  spiced  or  seasoned. 
Alcohol  in  all  forms,  together  with  coffee,  cocoa,  and  chocolate,  should 
be  strictly  prohibited. 

The  secretory  apparatus  of  the  skin  is  to  be  kept  in  order  by  means  of 
the  warm  bath,  followed  by  an  alcohol  rub  and  gentle  massage.  The 
bowels  must  be  regulated  by  mild  cathartic  pills,  rather  than  mineral 
waters  and  salines,  as  the  latter  are  apt  to  increase  the  urinary  irritation. 
The  local  pain  will  be  much  relieved  by  the  hot  sitz-bath,  and  also  rectal 
irrigations  of  hot  saline  solution,  taken  once,  twice,  or  even  more  fre- 
quently during  the  clay.  Hot  applications  over  the  bladder  and  on  the 
perineum  will  also  add  much  to  the  patient's  comfort.  If,  in  spite  of 
the  above  treatment,  the  frequency,  pain,  and  tenesmus  continue  to  dis- 
tress the  patient,  we  must  then  in  a  guarded  manner  employ  supposi- 
tories of  opium  or  belladonna  and  opium  combined.     These  failing  to 


CYSTITIS.  375 

give  relief,  we  may  use  codeine,  opium,  or  morphine  by  the  mouth,  or, 
in  extreme  and  very  severe  cases,  morphine  by  hypodermic  injection, 
always  bearing  in  mind  that  it  may  have  to  be  continued  for  some  time, 
and  therefore  there  is  great  danger  of  establishing  the  habit.  If  the 
urine  is  too  acid  in  reaction,  this  may  be  modified  by  the  internal  ad- 
ministration of  the  bicarbonate,  acetate,  or  citrate  of  potassium,  in  full 
doses,  either  alone  or  combined  with  a  little  tincture  of  hyoscyamus  or 
laudanum  for  their  quieting  and  soothing  effects ;  also  liquor  potassa?, 
with  laudanum,  uva  ursi,  and  triticum  repens.  Bicarbonate  of  sodium  in 
Vichy  water  gives  the  same  result,  and,  taken  cold,  is  a  pleasant  and 
refreshing  drink. 

These  cases  must  be  carefully  watched  for  retention  of  urine,  which 
may  add  greatly  to  the  patient's  distress,  and,  if  not  relieved  by  the 
hot  bath  and  rectal  irrigation,  gentle  and  sterile  catheterization  must  be 
resorted  to,  under  local  or  even  general  anaesthesia  in  very  sensitive  sub- 
jects. If  the  soft-rubber  catheter  fails,  the  surgeon  may  then  employ 
a  woven  one ;  and  this  also  being  unsuccessful,  a  silver  catheter  can  be 
tried,  or  suprapubic  aspiration  performed,  according  to  the  nature  of 
the  obstruction  and  the  requirements  of  the  case. 

In  a  small  minority  of  cases,  in  spite  of  the  above  treatment,  the  fre- 
quency in  urination  and  painful  tenesmus  may  continue,  and  can  some- 
times be  relieved  by  the  instillation  of  a  few  drops  of  nitrate  of  silver 
solution  (two  grains  to  the  ounce)  into  the  deep  urethra.  It  must  be 
clearly  understood,  however,  that  the  vast  majority  of  cases  do  not  re- 
quire this  treatment,  and  that  instillations  or  irrigations  in  the  bladder 
or  urethra  are  absolutely  contraindicated  in  the  acute  stages  of  cystitis, 
although  later  on  they  are  of  the  greatest  value. 

As  the  process  passes  into  a  chronic  condition,  the  alkaline  mixtures 
can  be  discontinued,  and  in  their  place  boric  acid,  either  alone  or  com- 
bined with  hyoscyamus  or  salol  may  be  given ;  and  if  the  urine  shows 
a  distinctively  alkaline  tendency,  urotropin  should  be  given  in  five  to 
seven  grain  doses  three  times  a  day.  This  remedy  is  most  valuable  in 
all  alkaline  conditions  of  the  urine,  since  it  restores  the  normally  acid 
reaction  and  induces  an  inhibitory  action  on  the  micro-organisms. 
When  the  acute  inflammatory  symptoms  have  subsided,  it  is  well 
to  begin  the  guarded  use  of  gentle  and  non-irritating  bladder  irriga- 
tions, given  by  means  of  a  soft-rubber  catheter  and  large  hand-syringe ; 
the  solutions  must  be  warm,  and  thrown  in  slowly  and  with  the  utmost 
gentleness  and  care,  the  flow  being  stopped  as  soon  as  the  patient  ex- 
periences the  slightest  local  irritation.  Then  the  catheter  should  be 
removed  and  the  patient  should  be  allowed  to  void  the  solution,  which 
washes  out  the  entire  urethral  canal.  This  treatment,  as  a  rule,  is  to 
be  given  once  a  day,  beginning  with  normal  salt  or  boric-acid  solution, 


376  AFFECTIONS  OF  THE  BLADDER. 

later  mild  washings  of  alum,  or  alum  and  zinc  in  combination ;  then  we 
may  employ  permanganate  of  potassium  (1  :  16,000  to  1  :  4000  or  even 
stronger) ;  and  finally  nitrate  of  silver  solution,  beginning  with  a  mild 
strength,  and  by  degrees  working  up  to  1  :  8000,  1  :  5000,  or  in  certain 
cases  even  higher.  Thiersch  solution,  and  also  solutions  of  salicylic 
acid,  bichloride  of  mercury,  and  many  other  preparations  may  be  em- 
ployed, but  in  the  writer's  experience  they  are  far  inferior  to  those  already 
given,  especially  the  nitrate  of  silver,  which  if  conservatively  used  will 
be  followed  by  most  brilliant  results. 

When,  as  a  result  of  the  above  treatment,  the  bladder  capacity 
becomes  normal  and  the  urine  is  clear  and  transparent,  but  still  con- 
tains flakes  and  shreds,  instillations  (see  page  84)  of  silver  nitrate 
should  be  substituted  for  the  irrigations.  By  this  time  the  patient 
may  be  sufficiently  well  to  perform  his  usual  duties  and  may  return  to 
regular  diet. 

If  the  case  is  complicated  by  calculous  disease,  the  stone  must  be 
removed  by  litholapaxy  or  a  cutting  operation ;  when,  on  the  other 
hand,  cystitis  is  aggravated  by  urethral  stricture,  prostatic  disease, 
tumor,  or  foreign  body,  these  conditions  must  be  treated  as  already 
described  under  these  affections.  These  same  remarks  apply  to  cases  in 
which  the  bladder  inflammation  is  associated  with  or  complicated  by  a 
tubercular  process. 

There  are  certain  rare  and  exceptional  cases  of  cystitis  which  re- 
sist all  forms  of  local  and  internal  treatment,  and  require  prolonged 
bladder  drainage,  either  perineal  or  suprapubic,  according  to  the  con- 
dition of  the  prostate  and  vesical  neck ;  the  choice  of  procedure  will 
then  rest  with  the  surgeon  after  a  careful  and  thorough  local  examina- 
tion, which  in  some  cases  will  be  greatly  aided  by  the  employment 
of  the  cystoscope. 

VESICAL   CALCULUS. 

Vesical  calculus  originates  primarily  either  in  the  kidney  or  in  the 
bladder,  and  increases  in  size  and  weight  by  the  addition,  in  super- 
imposed layers  around  the  nucleus,  of  any  of  the  urinary  salts,  which 
differ  according  to  the  chemical  composition  of  the  urine.  These  salts 
are  held  together  by  a  peculiar  albuminoid  or  colloid  material  furnished 
by  the  mucus  in  diseased  conditions  of  the  urinary  tract,  and  without 
which  stone-formation  does  not  occur,  even  when  certain  urinary  salts 
are  in  excessive  quantities. 

Calculus  is,  as  a  rule,  single,  although  many  may  be  found  in  the 
same  bladder,  especially  in  cases  with  a  deep  post-trigonal  pouch,  in 
which  latter  condition  their  surfaces  may  be  faceted  and  highly  polished. 
They  may  be  free  in  the  bladder,  adherent  to  its  walls,  or  more  or  less 


FIG.  3. 


FIG.  4. 


«** 


FIG.  5. 


FIG    6. 


VESICAL    AND    RENAL   CALCULI. 

Fig.  1.  Oxalate  ot  lime  calculus  (weight,  1200  grains). 

Fig.  2.  Showing  concentric  layers  of  oxalate  of  lime  calculus. 

Fig.  3.  Phosphatic  calculus  with  nucleus  of  wax. 

Fig.  4.  Mixed  calculus.    Chiefly  uric  acid. 

Figs.  5  and  6.    Renal  calculi  passed  through  the  urethra. 


VESICAL   CALCULUS. 


377 


encysted  in  pouches,  diverticula,  or  sacculi  (see  Plates  VI.  and  X.) ;  their 
weight  varies  from  a  few  grains  to  many  hundred  (see  Fig.  91),  and  their 
shape  according  to  the  nucleus  and  the  position  they  occupy  in  the  viscus. 
Oxalate  of  lime  calculi  (mulberry  calculus)  are  rare,  grayish-brown  to 
black  in  color,  the  hardest  of  all  in  structure,  and  present  a  rough  and  even 
knobby  surface  (see  Fig.  92  and  Plate  XIV.,  Fig.  1).  Uric  stones,  which 
are  composed  of  uric  acid  and  the  urates  (see  Plate  XIV.,  Fig.  4),  have 
a  smooth,  yellowish-red  surface  and  are  very  soft.  Phosphatic  calculi  (see 
Plate  XIV.,  Fig.  3),  made  up  of  phosphates  and  carbonates,  are  gray- 

Fig.  91. 


Very  large  vesical  calculus  and  phosphatic  crusts  with  chronic  cystitis. 


ish-white  in  color,  soft  and  easily  crushed,  and  present  a  quite  smooth 
or  rather  roughened  surface.  These  are  the  usual  varieties  of  stone 
met  with,  although  cystin,  xanthin,  cholesterin,  and  hsematoidin  cal- 
culi are  rather  exceptionally  seen.  Mixed  stones  are  very  commonly 
encountered,  their  alternate  layers  being  made  up  of  the  various  urinary 
salts,  according  to  the  chemical  composition  of  the  urine  at  the  time. 
Stones  sometimes  undergo  spontaneous  disintegration  or  fracture  in  the 
bladder.  This  is  supposed  to  be  due  to  a  sudden  change  in  the  specific 
gravity  and   reaction  of  the  urine,   which  acts  on  the  mucoid  frame- 


378 


AFFECTIONS   OF  THE  BLADDER. 


work  and  the  structure  of  the  different  layers  of  the  calculus,  and  in 
some  way  causes  its  disruption  into  many  fragments. 

The  vast  majority  of  calculi  originate  in  the  kidneys  upon  uric  acid 
or  oxalate  of  lime  nuclei.  They  usually  pass  down  the  ureters  into 
the  bladder,  either  with  or  without  symptoms  of  renal  colic,  and  escape 
through  the  urethra  (see  Plate  XIV.,  Fig.  5)  or  remain  in  the  bladder, 
where  they  increase  in  size  owing  to  the  deposition  of  superimposed 
layers  of  urinary  salts.  Many  calculi,  however,  originate  in  the  bladder 
itself  on  nuclei,  consisting  of  urinary  salts,  blood-clots,  ropy  pus,  and 
foreign  bodies,  which  latter  may  enter  that  viscus  as  a  result  of  accident 
(bullets,  missiles,  bits  of  bone,  clothing,  ends  of  catheters  and  bougies), 
or  are  purposely  introduced  by  sexual  perverts  for  sexual  gratification 
(pins,  hairpins,  bits  of  straw,  shoe-lace,  feathers,  pencils,  pen-holders, 
wax,  etc. — see  Plate  XIV.,  Fig.  3).  Cases  have  been  reported  in 
which  various  objects  having  been  swallowed  have  found  their  way  by 
ulceration  from  the  intestine  to  the  bladder,  where  they  have  become 
encrusted  with  urinary  salts.  Calculi  may  become  encysted  in  the 
bladder  (see  Plate  XV.). 

Symptoms. — Although  the  classical  symptoms  of  stone,  viz.,  in- 
creased frequency  and  sudden  stoppage  of  urination,  are  present  in 
many  cases,    there  are  some  in  which  these  symptoms  are  very  mild 


Fig.  92. 


Typical  oxalate  of  lime  mulberry  calculus. 

or  practically  absent.  This  is  especially  true  when  the  stone  is  smooth 
and  so  placed  or  held  that  it  does  not  press  upon  nor  irritate  the  sensitive 
vesical  neck.  Patients  have  been  known  to  carry  stones  for  some  time 
without  being  aware  of  their  presence,  until  they  were  discovered  acci- 
dentally by  the  surgeon  or  on  post-mortem  examination.  When  the 
bladder  is  full  there  may  be  more  or  less  dull  aching  pain  above  the 
symphysis,  in  the  groins,  the  thighs,  testes,  urethra,  and  penis,  espe- 
cially the  glans,  radiating  through  the  perineum  and  rectum.  This  is 
increased  when  the  patient  walks  or  drives,  and  is  diminished  when  he 


PLATE  XV. 


ENCYSTED  CALCULI  OF  BLADDER. 


VESICAL  CALCULUS.  379 

lies  on  his  side  or  back,  or  assumes  the  knee-chest  position,  which  rolls 
the  stone  away  from  the  sensitive  vesical  orifice.  Some  patients  suffer 
from  severe  reflex  pains  in  the  upper  or  lower  extremities,  especially 
along  the  sole  of  the  foot  and  in  the  great  toe.  As  a  result  of  the 
vesical  irritation  the  penis  is  sometimes  kept  in  a  state  of  painful  erec- 
tion, which  greatly  adds  to  the  patient's  suffering.  At  the  close  of  urina- 
tion the  pain  may  become  acute  and  intense,  owing  to  the  stone  being 
forced  against  the  inflamed  vesical  orifice.  This  pain  radiates  through 
the  penis  into  the  glans  and  causes  the  patient  to  press  and  drag  on 
the  organ  in  the  vain  hope  of  relief.  At  this  time  there  may 
be  violent  rectal  tenesmus  with  evacuation  of  the  bowel  contents. 
As  above  stated,  the  frequency  in  the  act  of  urination  is  increased  when 
the  patient  is  up  and  about,  and  decreased  when  in  the  recumbent  posi- 
tion. In  some  cases  the  stream  will  be  suddenly  stopped  by  the  stone 
blocking  the  vesical  orifice,  and  if  the  patient  changes  his  position  (as  he 
instinctively  learns  to  do)  the  stone  will  move  away  and  the  flow  com- 
mences.J  Hematuria,  which  is  caused  by  the  traumatism  of  the  stone 
against  the  bladder  mucous  membrane,  is  usually  slight  in  amount.  It 
is  increased  by  exercise  or  anything  that  causes  the  calculus  to  change 
its  position  in  the  bladder  cavity.  Cystitis,  which  may  be  absent  or 
slight  at  first,  soon  increases  in  severity,  and  thus  adds  to  the  patient's 
suffering  and  distress. 

Diagnosis. — The  patient  is  placed  upon  his  back,  with  head  and 
shoulders  slightly  elevated,  and  then,  under  local  or  general  anaesthesia, 
depending  upon  the  irritability  of  the  parts,  the  bladder  floor  and 
walls  are  gently  explored  as  follows :  A  clean  soft-rubber  or  woven- 
silk  catheter  is  passed,  the  urine  drawn,  the  bladder  irrigated  with 
warm  salt  or  boric  acid  solution,  from  four  to  six  ounces  of  which  are 
left  in,  thus  distending  the  viscus  and  effacing  the  vesical  folds.  A 
Thompson's  searcher  (see  Fig.  93),  either  solid  or  hollow,  is  passed  in 

Fig.  93. 


Thompson's  latest  searcher. 

a  careful  manner,  with  a  view  of  touching  the  stone,  and  when  en- 
countered a  peculiar  sensation  to  practised  fingers  is  conveyed.  The 
click  when  the  searcher  strikes  the  stone  can  sometimes  be  heard  un- 
less it  be  coated  with  blood  or  muco-pus.  The  hollow  or  catheter-like 
searcher  enables  the  examiner  to  lessen  the  amount  of  fluid  in  the  blad- 
der, which  is  sometimes  an  aid  in  detecting  stone  and  should  be  remem- 
bered, as  the  sudden  emptying  of  a   bladder  will  sometimes  bring   the 


380  AFFECTIONS  OF  THE  BLADDER. 

stone  directly  against  the  searcher.  Stones  sink  to  the  base  of  the 
bladder  unless  they  are  encapsulated  or  encysted  in  its  walls.  It  is 
well,  therefore,  to  explore  this  region  first,  and  then  the  remainder  of 
the  cavity.  If  there  is  marked  prostatic  hypertrophy,  it  may  be 
impossible  to  touch  the  stone  in  a  deep  post-trigonal  pouch,  which 
can  sometimes  be  elevated  by  raising  the  patient's  hips  or  by  a 
finger  passed  into  the  rectum  and  pressed  upward.  If  no  stone  is 
detected,  the  horizontal  position  may  be  changed  to  the  Trendelen- 
burg, knee-chest,  or  the  side,  the  idea  being  to  dislodge  an  impacted 
calculus.  The  searcher  failing,  we  may  make  an  ocular  examina- 
tion with  the  cystoscope,  and  by  its  aid  we  may  find  the  stone  if  it  be 
present,  or  obtain  data  as  to  the  existence  of  a  tumor  or  a  prostatic 
overgrowth  encrusted  with  urinary  salts.  Should  the  stone  not  be 
detected,  it  is  well  to  pass  an  evacuating  tube  attached  to  Bigelow's  evac- 
uator,  then,  when  pumping  is  commenced,  a  click  will  be  heard  or  felt 
from  contact  of  the  stone  with  the  instrument.  By  this  procedure  a 
swirl  of  the  bladder  contents  is  produced  which  dislodges  the  stone. 
As  a  last  resort,  a  small  exploratory  suprapubic  cystotomy  may  be 
done,  although  before  resorting  to  this  we  may  try  the  Eontgen  rays, 
which  sometimes,  although  not  invariably,  give  a  very  striking  picture. 
The  examination  being  over,  the  bladder  is  carefully  irrigated  with 
warm  boric-acid  or  salt  solution,  some  of  which  is  left  in,  and  the 
urethra  flushed  as  the  catheter  is  withdrawn.  The  patient  then  goes 
to  bed  or  is  kept  warm  and  quiet  in  the  house,  for  it  must  be  remem- 
bered that  this  examination  is  not  devoid  of  risk,  especially  in  elderly 
men  with  more  or  less  damaged  urinary  organs. 

Treatment. — In  regard  to  the  preventive  treatment  of  stone  forma- 
tion, either  in  the  kidney  or  the  bladder,  very  little  if  anything  can  be 
accomplished  unless  the  case  is  seen  at  an  early  date.  If  a  patient  has 
an  excess  of  crystals  in  the  urine,  or  is  passing  sand  and  gravel,  their 
chemical  composition  must  be  ascertained  and  proper  means  instituted 
to  correct  the  diathesis,  whether  it  be  uric  acid,  oxalic  acid,  or  phos- 
phatic ;  the  practical  point  being  to  render  the  urine  as  nearly  normal 
as  possible  by  proper  exercise,  food  and  drink,  and  internal  medication  : 
all  depending,  of  course,  upon  the  special  requirements  of  each  individ- 
ual case.  The  bladder  must  always  be  kept  sweet  and  clean,  and  the 
residuum  reduced  and  replaced  by  sterile,  non-irritating  irrigations. 

When  stone  has  formed,  however,  solvent  treatment  is  of  no  avail, 
and  the  foreign  body  should  be  removed  by  an  immediate  crushing  or 
cutting  operation,  the  choice  of  which  depends  upon  the  age  of  the 
patient,  the  condition  of  the  bladder  and  prostate,  and  the  size,  consist- 
ence, and  seat  of  the  stone. 

Lithoteity,  which  consists  of  the  crushing  of  the  stone  without  the 


LITHOLAPAXY 


381 


immediate  removal  of  its  fragments,  is  not  practised  at  the  present  time, 
having  been  superseded  and  replaced  by  litholapaxy.  The  technic  of 
the  operation  is  therefore  not  described. 

Litholapaxy. — In  this  operation  the  stone  is  crushed  and  its  frag- 
ments evacuated  or  pumped  out  at  one  sitting,  the  bladder  being  left 
free  and  clean.     In  practised  hands  it  is  the  operation  of  choice  for 


Bigelow's  lithotrite,  showing  slot  in  heel  for  escape  of  detritus. 

children  and  also  for  adults,  unless  the  patient  has  a  deep  post-trigonal 
pouch  with  marked  prostatic  hypertrophy,  which  renders  thorough 
crushing  and  evacuation  more  or  less  difficult,  but  not  impossible. 
Again,  some  stones  are  too  hard  or  large  or  inaccessible  to  be  grasped 
by  the  lithotrite,  and  these  require  in  children  perineal  lithotomy,  and  in 
adults  the  suprapubic  route.  For  the  proper  performance  of  lithola- 
paxy, we  must  have  a  bladder  capable  of  holding  several  ounces  of 


Fig.  95. 


Fig.  96. 


Beak  of  Bigelow's  lithotrite  (open). 


Beak  of  Bigelow's  lithotrite  (closed). 


fluid  (at  least  four),  and  a  meatus  and  urethra  that  will  admit  instru- 
ments of  sufficient  calibre  for  the  crushing  of  large  and  hard  stones ; 
these  points  should  be  ascertained  at  the  preliminary  examination. 

Operation. — The  rectum  having  been  thoroughly  emptied,  the 
patient  is  anesthetized  and  placed  on  his  back  with  thighs  separated, 
and  the  bladder  irrigated  with  boric-acid  solution,  six  to  eight  ounces 
of  which  are  left  in  and  retained  by  tying  a  tape  about  the  penis,  which 


382  AFFECTIONS  OF  THE  BLADDER. 

can  be  loosened  to  allow  the  passage  of  instruments.  A  non-fen estrated 
Bigelow's  lithotrite  (see  Fig.  94)  of  proper  size  (25  F.  to  31  F.)  is 
selected,  thickly  smeared  with  white  vaseline,  and  passed  into  the  blad- 

Fig.  97. 


Handle  of  Bigelow's  lithotrite  (closed; 


Handle  of  Bigelow's  lithotrite  (open). 


der,  its  convexity,  or  heel,  being  pressed  down  against  the  fundus  of  the 
bladder  and  in  the  median  line,  where  it  should  be  held  during  the 
operation.  The  blades  are  then  separated  (see  Fig.  95),  when  the  stone 
will,  as  a  rule,  roll  between  them.     They  are  closed  slowly  (see  Fig.  96), 


Fig.  98. 


Bigelow's  latest  evacuator. 


locked  (see  Fig.  97),  and  gently  rotated  to  see  that  no  vesical  mucous 
membrane  has  been  included  ;  the  handle  is  then  slowly  turned  and  the 
stone  crushed.  This  is  repeated  until  no  fragments  of  the  stone  can  be 
grasped,  when  the  lithotrite  is  tightly  closed  and  removed.      If  the 


L1TH0LAPAXY.  383 

stone  or  fragments  cannot  be  seized  in  this  manner,  the  surgeon  will 
have  to  rotate  carefully  or  even  invert  the  instrument  in  his  efforts  to 
pick  them  up,  always  bearing  in  mind  the  fact  that  they  gravitate  to 
the  bottom  of  the  bladder.  A  full-sized  straight  or  curved  Bige- 
low's  evacuating  tube  is  plentifully  lubricated  with  white  vaseline, 
passed  to  the  bladder,  and  held  exactly  as  the  lithotrite  was ;  it  is 
then  connected  with  Bigelow's  evacuator,  which  is  (see  Fig.  98) 
filled  with  warm  boric  acid  solution,  the  two  stop-cocks  opened,  and 
pumping  or  squeezing  of  the  rubber  bulb  commenced,  when  the  finely 
crushed  fragments  will  be  heard  to  click  as  they  rush  along  the  tube 
and  can  be  seen  dropping  into  the  glass  bulb.  The  pumping  is 
continued  until  fragments  cease  appearing.  The  tube  is  then  re- 
moved and  the  bladder  searched,  and  if  fragments  are  found,  crushing 
and  evacuating  are  continued  until  the  bladder  is  clean.  The  bladder 
is  then  irrigated  and  left  partially  filled  with  boric-acid  or  salt  solution, 
which  should  also  flush  out  the  entire  urethra. 

For  very  hard  and  large  stones  it  is  sometimes  best  to  do  the  first 
crushing  with  a  fenestrated  lithotrite,  as  it  cuts  through  the  stone  more 
easily  than  a  nbn-fenestrated  instrument ;  but  it  should  be  remembered 
that  it  is  also  more  liable  to  injure  seriously  the  bladder  mucous  mem- 
brane ;  the  surgeon  must  therefore  exercise  the  greatest  care  in  the  use 
of  this  instrument,  avoiding  nipping  and  cutting  of  the  bladder  walls. 
If  a  stone  or  fragment  is  lodged  or  held  in  a  deep  post-trigonal  pouch, 
it  may  sometimes  be  worked  out  with  the  beak  of  the  lithotrite,  or  by 
elevating  the  pouch  with  a  finger,  or  a  rubber  bag  placed  well  up  in  the 
rectum  ;  elevating  the  hip  or  rolling  the  patient  on  his  side  will  some- 
times accomplish  the  same  result. 

Should  a  fragment  become  impacted  in  the  eye  of  the  tube,  it  must 
always  be  pushed  back  into  the  bladder  with  a  stylet,  then  crushed 
and  evacuated. 

For  children  we  employ  lithotrites  of  about  No.  20  F.  and  even 
smaller  ones,  depending  upon  the  size  of  the  urethra ;  but  it  is  always 
best  to  select  the  largest  instrument  that  will  work  easily  in  the  canal. 

The  patient  is  given  an  opium  suppository  and  put  to  bed,  where  he 
is  kept  for  a  few  days  and  allowed  to  void  his  urine  naturally.  The 
bladder  and  urethra  are  washed  daily,  and  internal  medicine  sriven  as 
indicated  until  the  cystitis  is  cured.  Should  the  operation  be  followed 
by  complications,  such  as  epididymitis,  urinary  fever,  prostatitis,  ure- 
thritis, etc.,  these  conditions  must  be  treated  as  described  elsewhere  in 
this  work. 

Chismore's  evacuating  lithotrite  (see  Fig.  99),  which,  as  its  name 
implies,  is  a  crushing  and  evacuating  instrument  combined,  is  some- 
times of  service  in  grasping,  crushing,  and    evacuating  the  last    frag- 


384 


AFFECTIONS   OF  THE  BLADDER. 


ment.  The  shaft  of  the  male  blade  is  hollow,  with  an  aspirating  or 
evacuating  bottle  attached  to  its  proximal  end,  while  the  distal  end 
opens  at  the  heel  of  the  blade,  so  that,  when  the  blades  are  separated 
or  opened    and  aspiration  commences,  the  fragments  will   be    rushed 


Chismore's  evacuating  lithotrite. 

down  between  the  blades,  where  they  are  caught,  crushed,  and  evac- 
uated. 

The  operator  should  always  have  two  or  three  lithotrites,  a  full 
assortment  of  tubes,  two  evacuators,  and  a  searcher,  and  also  be  pre- 
pared to  do  a  cutting  operation  should  it  prove  necessary.  There  are 
many  varieties  of  lithotrites,  tubes,  and  evacuators ;  but  as  Bigelow's 
instruments  (and  for  special  indications  Chismore's)  are,  in  the  writer's 
experience,  so  much  superior,  a  description  of  the  others  is  deemed  un- 
necessary, since  they  are  merely  modifications  of  Dr.  Bigelow's  original 
instruments. 

Perineal  Lithotomy. — In  children  the  stone  maybe  removed  by  the 
perineal  incision,  provided  litholapaxy  is  absolutely  contraindicated  and 
the  surgeon  does  not  deem  a  suprapubic  cystotomy  advisable.  In 
adults,  however,  the  perineal  route  should  never  be  employed,  as  it  is 
far  inferior  to  either  litholapaxy  or  suprapubic  cystotomy,  on  account 
of  the  delicate  structures  at  and  around  the  vesical  neck,  which  may 
be  cut  or  bruised,  either  by  the  knife  or  forceps,  or  in  the  forcible 
withdrawal  of  the  calculus.  Hemorrhage  is  likely  to  be  severe, 
and  sometimes  difficult  to  control  on  account  of  the  depth  of  the 
wound. 

In  perineal  lithotomy  the  bladder  is  reached  by  a  perineal  incision, 
either  lateral  or  median.  The  technic  of  the  perineal  operations  is  not 
described  in  detail,  as  the  author  considers  them  most  inadvisable  and 
not  to  be  employed,  for  the  reasons  stated  above. 

Lateral  Lithotomy. — The  patient  being  in  the  lithotomy  position,  a 
curved  lithotomy  staff  with  lateral  groove  is  passed  into  the  bladder 
against  the  stone  if  possible,  and  held  firmly  in  the  median  line  by  an 
assistant,  who  at  the  same  time  retracts  the  scrotum,  thus  fully  exposing 
the  operative  field.  An  incision  is  then  made  about  one  inch  in  front 
of  and  a  little  to  the  left  of  the  anus,  downward  and  outward  for  about 


SUPRAPUBIC  CYSTOTOMY.  385 

three  inches,  care  being  taken  not  to  wound  the  rectum  ;  as  hemorrhage 
is  free,  the  vessels  should  be  caught  and  ligated  as  they  are  cut,  since  it 
is  very  essential  for  the  surgeon  to  have  a  dry  wound  in  this  operation. 
The  knife  is  now  thrust  into  the  groove  on  the  staff,  which  it  is  made  to 
follow,  thus  opening  the  neck  of  the  bladder  and  cutting  into  the  left 
lobe  of  the  prostate.  The  stone  is  now  grasped  with  the  forceps  and 
extracted  as  carefully  and  gently  as  possible,  so  as  to  avoid  unnecessary 
bruising  of  the  adjacent  structures  ;  the  bladder  is  to  be  drained  and 
irrigated  in  the  usual  manner. 

Median  Lithotomy. — In  this  operation  the  cutting  is  done  on  a 
curved  lithotomy  staff  with  a  median  groove,  the  membranous  urethra 
opened,  and  a  finger  passed  into  the  bladder,  in  this  manner  dilating 
the  prostatic  urethra,  through  which  the  stone  is  extracted  with  forceps. 
The  subsequent  treatment  is  the  same  as  that  just  described  in  the 
lateral  operation. 

Suprapubic  cystotomy,  or  epicystotomy,  is  always  the  operation 
of  choice  when  litholapaxy  cannot  be  properly  employed.  By  this 
route  we  can  see  and  palpate  the  prostate  gland  and  remove  its  project- 
ing portions  if  they  encroach  upon  the  vesical  orifice ;  we  can  also 
see  and  remove  tumors,  or  incrustations  that  are  sometimes  found  on 
ulcerated  surfaces,  either  in  the  bladder  wall,  or  upon  areas  of  prostatic 
overgrowth,  or  tumor. 

Operation. — The  patient  is  etherized,  placed  flat  upon  the  back, 
with  head  and  shoulders  elevated,  or  in  the  Trendelenburg  position,  and 
a,  soft  catheter  passed  into  the  bladder.  A  collapsed  and  well-greased 
rectal  bag  (colpeurynter)  is  then  placed  in  the  rectum  by  a  trained 
assistant;  the  bladder  is  irrigated  with  boric  acid  solution,  six  to  ten 
ounces  of  which  are  retained  by  tying  a  tape  around  the  penis.  The 
rectal  bag  is  slowly  distended  by  injecting  about  six  to  eight  ounces  of 
warm  water  through  its  tube,  which  is  then  clamped.  The  rectal  bag 
and  bladder  can  be  distended  with  air,  but  this  method  has  no  practical 
advantage  over  fluid. 

As  the  result  of  the  vesical  and  rectal  distention  the  bladder  rises 
up  from  the  pelvis,  thus  giving  the  surgeon  plenty  of  room  to  incise  its 
anterior  wall  without  wounding  the  fold  of  peritoneum  that  covers  this 
region  when  the  bladder  is  empty.  An  incision  is  now  made  directly 
in  the  median  line  upward  from  the  top  of  the  symphysis  for  about 
three  inches,  and  directly  down  until  the  prevesical  fat  is  exposed. 
This  must  never  be  torn  or  bruised,  but  rolled  gently  up  and  out  of  the 
way  with  the  finger-tip.  The  anterior  bladder  Avail  is  now  exposed, 
and  through  it  on  each  side  of  the  median  line  are  passed  silk  sutures 
which  act  nicely  as  retractors,  and  between  which  is  made  one  clean 
cut  with  a  sharp-pointed   knife.     As  the  fluid  gushes  out  of  the  wound 

25 


386  AFFECTIONS  OF  THE  BLADDER. 

the  stone  is  carefully  caught  with  straight  or  curved  stone-forceps  (see 
Fig.  100).     If  the  stone  is  too  large  to  be  removed  nicely  through  the 

Fig.  100. 


Curved  stone-forceps. 

suprapubic  wound,  it  should  be  crushed  with  forceps  and  taken  out 
piecemeal  in  a  gentle  manner,  great  care  being  taken  not  to  injure  the 
cut  bladder  edges  and  the  wound  surfaces  in  general.  This  step  in 
the  operation,  if  damage  is  done,  will  lead  to  more  or  less  prevesical 
sloughing  and  necrosis,  with  perhaps  pus  formation.  The  bladder  cav- 
ity and  prostate  are  then  explored  by  the  aid  of  artificial  light,  and 
abnormal  conditions  corrected  if  deemed  advisable. 

The  bladder  is  washed  and  drained  by  means  of  a  large  soft-rubber 
tube  with  two  eyes,  and  its  edges  are  sewed  tightly  around  the  tube,  thus 
preventing  escape  of  urine  into  the  prevesical'  space.  The  ends  of 
the  wound  are  closed  by  deep  sutures,  but  its  central  portion  is  left 
open  and  lightly  packed  with  strips  of  sterile  gauze,  which  will  prevent 
leakage  or  secretion  escaping  into  the  prevesical  space.  In  a  day  or 
so,  a  smaller  tube  is  substituted,  and  as  soon  as  possible  all  drainage 
removed  and  the  wound  allowed  to  granulate,  which  it  always  will 
if  proper  care  is  exercised  by  the  surgeon.  A  tight  stricture  or  an 
abnormally  small  meatus  will  for  obvious  reasons  interfere  with  the 
proper  healing  of  the  wound,  and  they  should  therefore  receive  proper 
treatment  before  the  operation. 

Many  elaborate  methods  for  suprapubic  drainage  are  described,  but 
the  single  tube,  connected  to  a  long  rubber  tube  by  means  of  a  glass 
coupler,  and  terminating  beneath  the  bed  in  a  bottle  one-quarter  filled 
with  bichloride  solution,  will  meet  all  the  requirements  of  these  cases. 

The  cystitis  which  complicates  stone  is  treated  in  the  usual  manner 
by  internal  and  local  medication,  until  the  patient  passes  clear  urine  in 
a  normal  manner. 

VESICAL  TUMORS. 

Bladder  tumors  are  either  benign  or  malignant  in  character,  the  former 
including  papillomas,  or  villous  tumors  (see  Plate  XVI.),  adenomas,  fibro- 
mas,  cysts,  and  myxomas;  and  the  latter  carcinomas  (see  Plate  XVII.), 
sarcomas,  and  mixed  tumors.  The  majority  of  bladder  growths  are 
malignant,  a  fact  which  should  be  borne  in  mind  by  the  surgeon  when 
making  a  prognosis  and  advising  a  plan  of  treatment.     As  a  rule,  they 


PLATE  XVI. 


VILLOUS  TUMORS  OF  BLADDER. 


PLATE  XVII. 


CARCINOMA  OF  BLADDER  AND  RECTUM. 


VESICAL   TUMORS. 


387 


are  situated  at  the  base  of  the  bladder,  but  may  occur  ou  any  por- 
tion of  its  walls,  to  which  they  are  attached  either  by  well-marked  pedi- 
cles or  flattened  bases.  They  may  appear  at  almost  any  age,  but  usu- 
ally are  encountered  after  middle  life.  Papilloma  is  the  commonest 
form  of  benign  growth,  while  carcinoma  represents  the  usual  type  of 
malignant  disease  (see  Fig.  101). 

Symptoms. — The  symptoms  of  bladder  tumor  vary  greatly,  as  a 
result  of  the  situation  of  the  growth  and  whether  it  be  benign  or 
malignant.  A  papilloma  on  the  bladder  wall  may  exist  for  years  with- 
out the  patient's  knowledge,  whereas,  if  it  was  seated  on  the  trigonum 
or  near  the  vesical  orifice,  there  would  be  more  or  less  frequency  in 
urination  with  perhaps  hematuria  and  occasional  interruption  of  the 
stream.  Carcinomas  and  sarcomas  usually  make  their  presence  known 
by  pain,  irritation,  and  the  final  development  of  cystitis.  Hemorrhage 
may  be  trifling  or  so  free  as  to  exhaust  the  sufferer,  who  apparently 
passes  large  amounts  of  bright-red  blood.  If  coagulation  occurs  in 
the  bladder,  the  vesical  orifice  is  liable  to  become  occluded  with  clots, 
thus  causing  retention  and  great  suffering.  The  bleeding  may  cease  for 
days  at  a  time,  and  then  suddenly  occur  without  apparent  cause,  and 
as  suddenly  stop  for  a  longer  or  shorter  period.     The  passage  of  clots 

Fig.  101. 


Carcinoma  of  bladder. 


and  small  fragments  of  tumor  by  way  of  the  urethra  often  causes  the 
patient  great  pain  and  distress,  unless  they  are  expelled  without  ob- 
struction. 


388  AFFECTIONS  OF  THE  BLADDER. 

Diagnosis. — The  diagnosis  of  vesical  tumor  is  arrived  at  by  a  care- 
ful consideration  of  the  history  of  the  case  and  the  condition  of  the 
patient,  in  regard  to  the  pain,  frequency  in  urination,  and  hemorrhage. 
A  rectal  exploration  will  exclude  trouble  in  the  prostate,  vesicles, 
and  ampullco.  A  microscopic  examination  of  the  urine,  blood-clots, 
and  especially  the  small  fragments  of  neoplasm  passed  by  the  urethra, 
will  be  most  valuable  in  establishing  a  correct  diagnosis.  It  is  there- 
fore desirable  to  have  these  patients  urinate  into  a  vessel  and  to  save 
all  such  masses.  If  the  urine  or  the  injected  fluid  can  be  kept  fairly 
clear,  either  by  irrigation  of  the  bladder  or  the  irrigating  cystoscope, 
much  valuable  aid  will  be  given  by  a  cystoscopic  examination  of  the 
viscus,  which  shows  the  size,  situation,  and  general  make-up  of  the 
growth,  and  whether  it  is  pedunculated  or  sessile,  and  if  it  is  covered 
with  an  incrustation  of  urinary  salts,  which  latter  condition  gives  a  most 
beautiful  cystoscopic  picture  in  the  bright  illumination  of  the  electric 
light.  In  some  cases  the  contact  of  the  beak  of  the  cystoscope  will  start 
sudden  oozing  of  blood  from  the  surface  of  the  tumor,  while  in  others 
the  mass  can  be  touched  with  impunity.  If  bleeding  be  so  profuse 
that  the  cystoscope  cannot  be  employed,  the  mass  can  sometimes  be  felt 
with  a  stone-searcher  or  catheter  passed  gently  over  the  entire  sur- 
face of  the  bladder  mucous  membrane.  Should  this  method  fail  and  a 
tumor  be  suspected,  an  exploratory  suprapubic  cystotomy  will  reveal 
the  true  condition.  Bimanual  palpation  is  only  of  aid  when  the  tumor 
is  very  large  and  firm. 

Treatment. — Vesical  growths  should,  as  a  rule,  be  removed  for  the 
following  reasons  :  they  are  liable  to  malignant  degeneration,  to  be  the 
■cause  of  serious  and  even  fatal  hemorrhage,  and  they  are,  as  a  rule, 
sooner  or  later  complicated  by  a  cystitis  which  in  time  may  travel  up 
the  ureter  and  infect  the  kidney.  Should  radical  operation  be  out  of 
the  question  or  refused,  the  surgeon  may  endeavor  to  check  the  hemor- 
rhage with  bladder  irrigations  of  hot  alum  or  nitrate  of  silver  solutions, 
combined  with  ergot  or  gallic  acid  taken  by  the  mouth,  the  patient  being 
kept  in  bed  and  quieted  by  the  guarded  use  of  codeine,  opium,  or  mor- 
phine. If  there  is  much  tenesmus,  with  clotting,  it  is  well  to  drain 
the  bladder  by  means  of  a  large  urethral  catheter  having  one  or  two 
good-sized  eyes. 

Suprapubic  cystotomy  (see  page  385)  is  always  the  operation  of  choice 
in  these  cases,  as  it  enables  the  surgeon  to  see  the  entire  bladder  mucous 
membrane.  The  wound  should  be  well  retracted,  and  on  slightly  elevat- 
ing the  head  and  shoulders,  and  thus  relaxing  the  abdominal  muscles, 
a  larger  working  field  than  is  afforded  by  the  Trendelenburg  position  is 
obtained.     The  base  of  the  bladder  may  be  elevated  by  the  rectal  bag. 

Perineal   cystotomy  has  its  advocates,  as  has  also  the  removal  of 


TUBERCULOSIS.  389 

tumors  by  the  so-called  operating  cystoscopes ;  but,  as  neither  of 
these  methods  has  any  practical  advantages,  they  are  not  to  be  com- 
mended or  employed. 

If  the  tumor  has  a  well-marked  pedicle,  it  should  be  cut  off  with  long 
curved  scissors  at  its  junction  with  the  bladder  wall ;  if,  on  the  other 
hand,  the  tumor  is  sessile  and  malignant  in  character,  more  or  less  of 
the  bladder  wall  must  be  resected,  in  order  to  include  if  possible  all  of 
the  infected  tissue.  In  some  cases  it  may  be  necessary  to  make  a  very 
extensive  resection  of  the  bladder,  with  perhaps  transplantation  of  the 
ureter.  It  is  always  a  grave  question,  however,  if  such  a  radical 
procedure  is  warranted  by  the  results. 

The  tumor  having  been  removed  and  hemorrhage  controlled  by  the 
Paquelin  cautery,  hot  irrigations,  and  packing,  the  bladder  is  drained 
by  two  suprapubic  tubes,  or  one  suprapubic  and  one  perineal  tube, 
according  to  the  requirements  of  the  case.  The  bladder  wall  is  sewed 
tightly  around  the  drain,  but  the  wound  in  the  soft  parts  should  be  left 
open  and  drained  with  strips  of  sterile  gauze,  which  will  absorb  any 
urine  or  fluid  accumulation  which  tends  to  escape  into  the  prevesical 
space.  The  tubes  are  removed  as  soon  as  possible  and  the  wound 
allowed  to  granulate  from  the  bottom.  The  bladder  is  kept  clean  by 
warm  and  non-irritating  irrigations,  and  the  urine  rendered  bland  by 
internal  medication  according  to  its  reaction. 

TUBERCULOSIS. 

Although  vesical  tuberculosis  may  be  primary,  yet  in  the  vast  major- 
ity of  cases  it  is  secondary  to  and  associated  with  similar  disease  in 
the  kidneys,  prostate,  seminal  vesicles,  or  epididymis,  the  infecting 
agent  (tubercle  bacillus)  coming  down  from  the  kidney,  or  passing 
upward  from  the  prostate  gland,  seminal  vesicle,  or  epididymis. 

Bladder  tuberculosis  may  occur  at  almost  any  age,  but  is  most  fre- 
quently encountered  when  the  sexual  organs  are  active — that  is,  from 
about  the  fifteenth  to  the  twenty-fifth  year.  In  some  instances,  the  suf- 
ferer gives  a  history  of  masturbation  or  a  previous  urethritis,  while  in 
others  there  is  no  evidence  of  antecedent  irritation  of  the  urinary 
tract. 

Symptoms. — As  vesical  and  prostatic  tuberculosis  are  usually  asso- 
ciated with  each  other,  the  symptoms  are  more  or  less  complex,  depend- 
ing upon  the  advancement  of  the  disease  in  either  one  or  both  organs. 
As  a  rule,  the  first  symptom  is  increased  frequency  in  urination,  which 
may  or  may  not  be  painful  and  followed  by  a  little  blood.  As  the  in- 
fection progresses,  the  urine,  which  was  at  first  clear,  assumes  a 
cloudy  appearance  caused  by  the  commencing  cystitis,  which,  as  it 
increases  in  severity,  gives  rise  to  frequent  and   very  painful  urination 


390 


AFFECTIONS  OF  THE  BLADDER. 


day  and  night,  each  act  being  followed  by  painful  tenesmus.  Hema- 
turia, which  is  marked  in  some  cases,  is  practically  absent  in  others. 
The  symptoms  are  really  those  of  a  very  acute  and  intense  gonorrheal 
urethrocystitis.  As  the  tubercular  process  involves  the  vesical  neck,  it 
may  cause  retention  in  some  cases,  and  incontinence  in  others,  owing  to 
irritation  which  it  produces. 

Diagnosis. — A  correct  diagnosis  can  usually  be  arrived  at  by  a 
urinary  examination  for  tubercle  bacilli,  a  rectal  exploration  to  ascer- 
tain the  involvement  of  the  prostate  and  seminal  vesicles,  and  lastly  a 
cystoscopic  inspection  of  the  bladder  mucous  membrane,  which  reveals 
areas  and  spots   of  infiltration,  granulation,  sometimes  of  ecchymosis, 

Fig.  102. 


Tuberculosis  of  the  bladder. 


and  later  of  ulceration,  which  is  usually  annular  in  form  (see  Fig.  102). 
The  ulcers  may  be  single  or  multiple,  may  have  thickened  and  under- 
mined edges,  and  may  be  superficial,  or  so  deep  as  to  lead  to  perfora- 
tion.     The  bladder  walls  are  more  or  less  thickened  and  roughened, 


CYSTOSCOPY.  391 

and  the  capacity  of  the  viscus  is  diminished.  The  patient's  history, 
both  personal  and  family,  must  be  taken  into  consideration.  All  in- 
strumental examinations  in  these  cases  must  be  conducted  with  the 
utmost  care  and  gentleness,  since  traumatism  of  any  kind  is  very  apt  to 
be  followed  by  an  acute  exacerbation  of  the  disease.  Cystoscopy  and 
sounding  should  therefore  never  be  employed  unless  absolutely  essential. 
Treatment. — These  patients  should,  if  possible,  be  removed  to  a 
suitable  climate,  and  receive  the  usual  constitutional  treatment  indicated 
for  tubercular  subjects.  By  internal  medication  we  should  try  to  render 
the  urine  as  bland,  aseptic,  and  non-irritating  as  possible.  In  regard  to 
the  local  treatment  of  these  cases  by  bladder  irrigations  or  surgical  in- 
tervention, there  is  a  great  diversity  of  opinion,  the  majority  being  in 
favor  of  trusting  to  climatic  change  and  constitutional  treatment  until 
conditions  arise  that  demand  temporary  surgical  relief,  as,  for  example, 
suprapubic  drainage  when  tenesmus  becomes  constant  and  unbearably 
painful,  rather  than  to  undertake  any  radical  operation  with  a  view  of 
eliminating  a  disease  which  has  already  attacked  the  surrounding  struct- 
ures and  cannot  therefore  be  wholly  eliminated  by  the  knife.  As 
the  patient's  suffering  increases  opium  must  be  employed  in  a  careful 
and  intelligent  manner,  always  bearing  in  mind  that  it  may  have  to  be 
used  for  a  long  time.  Among  bladder  irrigations,  iodoform  in  emul- 
sion, and  bichloride  of  mercury  in  watery  solution,  hold  first  place,  but 
must  not  be  employed  without  due  thought  and  consideration.  The 
local  treatment  will  be  indicated  by  the  character  of  the  urine,  the 
stage  of  disease,  and  the  involvement  of  adjacent  organs. 

CYSTOSCOPY. 

The  illumination  of  the  bladder  and  its  visual  examination  by  means 
of  the  electric  cystoscope  is  undoubtedly  of  the  greatest  value  in  diag- 
nosticating certain  diseased  conditions  of  that  viscus  and  also  of  the  kid- 
ney, but  it  must  not  be  used  in  a  routine  and  haphazard  manner,  nor  em- 
ployed until  we  have  endeavored  to  make  the  diagnosis  by  the  usual 
methods.     Then,  the  case  demanding  it,  cystoscopy  should  be  practised, 

The  patient  is  placed  on  his  back  with  knees  flexed  and  widely  sep- 
arated, and  then  under  local  or  general  anaesthesia  a  suitable  cystoscope 
(see  Fig.  103),  and  one  to  which  the  surgeon  is  accustomed,  anointed 
with  glycerin,  is  passed  into  the  bladder,  the  electric  current  turned 
on,  and  the  surgeon,  sitting  on  a  low  stool,  examines  every  portion  of 
the  vesical  mucous  membrane  and  the  orifices  of  the  ureters,  from  which 
either  the  urine,  blood,  or  pus  can  be  seen  to  escape  every  few  seconds. 
Tumors,  projecting  prostatic  overgrowths,  stones,  foreign  bodies,  ulcera- 
tions, trabecular,  diverticula,  etc.,  can  be  seen  and  studied  by  the  prac- 
tised eye  ;  but  the  cystoscopic  picture    will  be   very  confused  and  in- 


392  AFFECTIONS  OF  THE  BLADDER.  . 

definite  to  the  beginner,  who  should  first  acquaint  himself  with  the  con- 
dition of  the  normal  bladder  before  he  'tries  to  study  pathological  con- 
ditions. For  a  satisfactory  examination,  the  following  conditions  are 
necessary  :  a  urethra  that  will  admit  at  least  a  No.  22  French,  a  bladder 
containing  from  four  to  six  ounces  of  clear  urine,  or  the  same  amount 

Fig.  103. 


Leiter's  cystoscope. 

of  a  clear  solution,  or  a  solution  that  can  be  kept  clear  by  means  of  the 
irrigating  cystoscope  (see  Fig.  103).  The  examiner,  and  especially  the 
beginner,  must  always  bear  in  mind  the  above  practical  points,  and  not 
undertake  a  cystoscopic  examination  in  a  contracted  bladder  whose  con- 
tents are  rendered  opaque  by  the  admixture  of  pus  or  blood  arising 
from  either  kidney,  bladder,  or  prostate.     (See  Plate  XVIII.) 

VARIOUS  STRUCTURAL  CONDITIONS. 

The  bladder  may  be  absent  in  part  or  in  its  totality,  the  ureters 
opening  into  the  rectum,  vagina,  urethra,  or  other  abnormal  localities. 
In  fact,  this  viscus  may  be  malformed  or  malplaced  in  a  great  variety  of 

Explanation  of  Plate  XVIII.     (After  Nitze.) 

Fig.  1  represents  the  mucous  membrane  and  the  arrangement  of  the  vessels  in  the 
healthy  bladder. 

Fig.  2  represents  a  condition  which  is  very  frequently  found  and  is  almost  typical ; 
both  lateral  lobes  are  hypertrophic  and  form  large  symmetrical  prominences  encroaching 
upon  the  interior  of  the  bladder ;  the  internal  orifice  is  situated  between  them.  At  the 
point  of  the  angle  a  small  piece  of  mucus  is  seen  adherent. 

Fig.  3.  Phosphatic  concretion  from  a  patient  suffering  from  prostatic  disease ;  to  the 
right  a  part  of  the  hypertrophic  fold  of  the  internal  orifice  is  seen. 

Fig.  4.  Showing  a  uric  acid  calculus  and  in  the  upper  part  of  the  figure  the  furrowed 
mucous  membrane  of  the  floor  of  the  bladder. 

Fig.  5.  Showing  villous  tumor  of  the  bladder. 

Fig.  6.  Becent  miliary  tubercles  from  the  bladder  of  a  patient,  aged  forty-three, 
forming  groups  of  small  globular  nodules  arranged  very  much  like  vesicles  in  herpes. 
They  are  sufficiently  distinguished  from  the  otherwise  healthy  mucous  membrane  by  their 
dull-pink  color. 


PLATE  XVIII. 


APPEARANCES  REVEALED  BY  THE  CYSTOSCOPE. 


PLATE  XIX. 


EXTENSIVE  RUPTURE  OF  BLADDER, 
showing  peritoneal  surface. 


PLATE  XX. 


RUPTURE  OF   BLADDER, 
from  within. 


TEA  UMA  TISMS.  393 

ways,  but  it  must  be  remembered  that  these  conditions  are  extremely 
rare. 

Exstrophy. 

Exstrophy,  or  extroversion  of  the  bladder  (ectopia  vesica?),  is  due 
to  lack  of,  or  insufficient  development  of,  the  anterior  abdominal 
walls  and  the  symphysis  pubis ;  the  anterior  wall  of  the  bladder,  the 
posterior  wall  with  the  ureters  is  pushed  forward  and  bulge  out  of 
the  abdominal  opening.  In  these  the  urine  trickles  out  over  the  sur- 
rounding integument,  and  it  becomes  reddened  and  excoriated.  The 
patch  or  piece  of  bladder  mucous  membrane  is  usually  intensely  con- 
gested, sodden,  and  bleeds  readily  on  manipulation.  The  testes  may  be 
present  in  the  scrotum  or  they  may  be  retained.  In  some  cases  there 
is  a  complicating  hernia.  The  deformity  is  more  common  in  the  male, 
in  whom  it  is  usually  associated  with  epispadias. 

Treatment.— The  object  to  be  attained  in  the  treatment  of  these 
cases  is  the  collection  and  removal  of  the  urine  without  irritating  the 
integument  and  soiling  the  clothing.  This  can  be  more  or  less  per- 
fectly accomplished  by  the  use  of  a  suitable  urinal,  which  should  be 
worn  day  and  night,  or  a  plastic  operation  may  be  performed,  either 
with  or  without  transplantation  of  the  ureters.  If  the  cleft  is  very 
wide,  a  flap  of  the  integument  from  the  abdominal  wall  (Wood's 
operation)  can  be  utilized  to  form  a  new  anterior  bladder  wall.  In  this 
event  the  hair- follicles  should  be  previously  destroyed,  since  the  pres- 
ence of  hairs  would  naturally  favor  the  development  of  stone,  and 
thus  add  to  the  patient's  distress.  If,  however,  the  cleft  is  not  too 
broad,  the  best  results  follow  suturing  of  the  edges  or  borders  of  the 
bladder  wall  together,  as  this  gives  us  a  viscus  which,  although  very 
small,  is  lined  with  mucous  membrane  and  it  can  be  fitted  with  an  ap- 
paratus which  collects  the  urine  from  an  opening  in  its  most  dependent 
part. 

TRAUMATISMS. 

The  bladder  may  be  punctured,  incised,  torn,  or  contused,  as  a 
result  of  gunshot-wounds,  stab-wounds,  ^fracture  of  the  pelvis,  and 
general  injuries.  These  accidents  are  much  more  liable  to  occur  when 
that  viscus  is  distended  and  elevated  than  when  it  is  empty,  contracted, 
and  deeply  seated  in  the  pelvis  behind  the  symphysis. 

Rupture  of  the  Bladder. 

A  distended  bladder,  the  result  either  of  violence  or  of  pathological 
changes  (weakness)  in  its  walls,  may  rupture ;  the  rent  being  more  fre- 
quently intraperitoneal  than  extraperitoneal.  (See  Plates  XIX.  and 
XX.) 

Symptoms. — If  the  patient  is  not  intoxicated  at  the  time  of  the 


394  AFFECTIONS  OF  THE  BLADDER. 

accident  (and  he  very  frequently  is),  he  complains  of  a  sudden  pain,  or  as 
if  something  had  "broken"  or  "given  away"  in  the  suprapubic  region. 
This  is  quickly  followed  by  a  constant  and  imperative  desire  to  urinate, 
which  when  attempted  is  fruitless.  The  patient  passes  blood  and  a  little 
urine,  or  nothing  at  all,  but  each  act  is  followed  by  severe  tenesmus.  If 
the  nature  of  the  injury  is  not  recognized  and  proper  treatment  em- 
ployed, the  patient's  condition  grows  gradually  worse  until  he  passes 
into  a  state  of  shock,  and  finally  succumbs  from  septic  peritonitis  or 
pelvic  cellulitis,  as  the  urine  in  these  cases  is,  as  a  rule,  not  normal 
(sterile).  If,  on  the  other  hand,  the  treatment  is  prompt  and  efficient, 
the  patient's  chances  are  much  better  ;  but  the  prognosis  is  always  grave, 
especially  in  intraperitoneal  cases  with  entrance  of  septic  urine  into  the 
peritoneal  cavity. 

Diagnosis. — The  previous  history  and  present  condition  having  been 
carefully  considered,  the  abdomen  is  palpated  and  the  rectum  exam- 
ined. The  former  procedure  will  aid  us  in  extraperitoneal  rupture,  and 
the  latter  in  the  intraperitoneal  variety,  when  there  will  be  more  or 
less  tumefaction  in  Douglas's  cul-de-sac  and  the  adjacent  tissues.  The 
bladder  walls  can  then  be  examined  with  the  aid  of  a  gum-elastic  or 
silver  catheter,  which  if  the  eye  is  not  occluded  with  a  clot  may 
allow  of  the  escape  of  blood  or  bloody  urine.  It  may  happen  that  the 
point  of  the  catheter  may  catch  in  a  rent  or  tear,  or  even  pass 
through  it.  Through  this  catheter  a  known  quantity  of  warm  sterile 
salt  solution  can  be  gently  injected,  and  if  the  same  amount  is  not 
withdrawn,  the  missing  quantity  must  have  escaped  into  the  surround- 
ing tissues  or  peritoneal  cavity.  This  test  is  not  to  be  relied  upon 
absolutely,  as  the  catheter  may  become  plugged  with  clots,  the  tear 
may  be  so  made  that  the  bladder  will  hold  fluid  unless  great  force  is 
used,  or  the  wound  may  have  been  closed  quickly  by  plastic  exudation. 
Cystoscopy  is,  as  a  rule,  of  little  aid  on  account  of  the  hemorrhage. 
The  above  methods  having  failed  to  establish  a  correct  diagnosis,  the 
patient  is  etherized  and  an  exploratory  suprapubic  cystotomy  per- 
formed (see  page  385),  when  the  surgeon  can  make  a  visual  examination 
of  the  bladder  surface,  and  locate  the  injury. 

Treatment. — When  the  rent  in  the  bladder  wall  is  extraperitoneal, 
it  may  be  closed  and  the  patient  catheterized  continuously ;  or,  better 
still,  it  may  be  left  open  and  drained  by  the  ordinary  suprapubic  method  ; 
the  prevesical  space  being  lightly  packed  with  gauze,  which  prevents 
infiltration  into  the  surrounding  tissues.  Thorough  cleansing  and 
drainage  of  the  prevesical  space  are  most  important;  therefore  the  sur- 
geon should  always  be  on  the  lookout  for  signs  of  burrowing  or  sup- 
puration in  this  and  the  perineal  region.  If,  however,  the  rent  is 
intraperitoneal,   laparotomy  should  be  performed  and  the  tear  in  the 


FOREIGN  BODIES.  395 

bladder  wall  should  be  tightly  closed  by  several  interrupted  sutures,  so 
as  to  prevent  further  leakage  of  urine  into  the  peritoneal  cavity.  Ex- 
isting conditions  are  treated  according  to  general  surgical  principles, 
and  the  abdominal  wound  closed,  except  at  its  lower  portion,  which 
should  be  left  open  and  drained  with  strips  of  gauze.  The  bladder  is 
to  be  drained  for  a  few  days  by  means  of  a  permanent  urethral  catheter 
or  perineal  tube,  through  either  of  which  it  should  also  be  gently 
irrigated. 

FOREIGN  BODIES. 

Foreign  bodies  gain  access  to  the  bladder  either  by  way  of  the 
urethra  or  through  its  walls  as  a  result  of  injury  or  ulceration.  Sexual 
perverts  not  infrequently  introduce  hair-pins,  pieces  of  shoe-lace,  straw, 
pencils,  pen-holders,  long  pieces  of  wax,  and,  in  fact,  all  kinds  and 
varieties  of  articles,  with  the  view  of  gratifying  their  abnormal  sexual 
cravings.  The  ends  of  catheters,  bougies,  etc.,  may  break  off  in  the 
bladder,  and  therefore  the  surgeon  should  always  see  that  these  instru- 
ments are  in  good  condition  before  introducing  them.  As  a  result  of 
injury,  bullets,  missiles,  bits  of  shell  and  bone,  clothing,  etc.,  may  enter 
the  bladder.  Solid  articles  swallowed  accidentally  by  patients  have 
been  known  to  pass  from  the  intestine  to  the  bladder  by  ulceration  of 
their  walls. 

The  symptoms,  which  may  be  absent  or  trifling  at  first,  soon  become 
marked,  as  the  foreign  body  is  rapidly  incrusted  with  urinary  salts, 
causing  the  usual  symptoms  of  stone. 

The  diagnosis  is  readily  made  from  the  history  of  the  case  and  the 
symptoms,  followed  by  exploration  of  the  bladder  with  a  stone- 
searcher,  and  the  electric  cystoscope  if  the  surgeon  cares  to  see  the 
shape  and  conformation  of  the  foreign  body,  since  this  information  will 
aid  him  greatly  in  the  choice  of  operation. 

Treatment. — If  the  object  is  small  and  soft  or  brittle,  it  may  be 
caught  with  a  lithotrite  and  removed,  or  crushed  and  evacuated  as  in 
litholapaxy.  If,  however,  this  plan  of  treatment  is  contraindicated, 
the  bladder  can  be  opened  either  by  a  small  suprapubic  or  by  a  perineal 
incision.  Special  instruments  for  the  removal  of  foreign  bodies  have 
no  advantages  whatever  over  the  above  method,  and  are  therefore  not 
described. 


CHAPTER    XIX. 

AFFECTIONS    OF    THE    URETERS. 

The  ureters  may  be  double,  multiple,  or  absent ;  they  may  pursue 
an  abnormal  course,  emerging  from  any  part  of  the  kidney  other  than 
its  inner  border,  and  terminate  extravesically.  Their  calibre  may  be 
diminished  or  occluded  by  stone,  stricture,  or  valve-like  folds.  They 
may  be  the  seat  of  tumors,  fistulse,  or  tuberculous  disease. 

THE  SHAPE  OF  THE  URETER. 

The  ureter  is  not  a  uniform-calibred  tube,  but  consists  of  ureteral 
dilatations  and  constrictions.  Calculi  lodge  at  the  ureteral  isthmuses  or 
constrictions,  as  well  as  at  the  turns  of  flexions.  The  following  facts 
are  taken  from  Byron  Robinson's  essay  on  the  shape  of  the  ureter  (see 
Fig.  104) : 

Fig.  1  illustrates  the  shape  of  ten  ureters  distended  with  paraffin, 
demonstrating  (a)  the  three  ureteral  dilatations,  spindles  (reservoirs)  (2,  4, 
6) ;  (6)  the  three  constrictions,  sphincters  (3,  5,  7),  and  (c).  The  spirality 
was  noted  while  distending  the  ureters  with  melted  paraffin.  The  free 
ureter  would  rotate  from  right  to  left  about  two  circles. 

Nos.  1  (left)  and  2  (right) ;  man,  aged  forty-six  years.  This  pair 
show  the  left  calcyces  (1,  1)  dilated  and  a  well-developed  pelvis  (2). 
The  left  proximal  ureteral  isthmus  (3)  well  marked  and  distalward 
located ;  the  right  (3)  indistinct  and  elongated,  less  constricted.  The 
left  lumbar  spindle  (4)  the  most  prominently  developed  and  the  more 
distalward  located.  The  middle  isthmuses  (5,  5)  moderately  marked. 
In  each  ureter  two  pelvic  spindles  (6,  6)  exist.  The  distal  isthmuses  (7, 
7)  were  less  in  lumen  than  the  proximal  (3,  3). 

The  left  ureter  (1)  presented  five  well-marked  spinal  ridges  projecting 
in  the  ureteral  lumen.  All  ureteral  dilatations  are  more  prominent  in  the 
left.     The  left  ureter  (1)  was  one  inch  longer  than  the  right  (2). 

The  left  ureter  (1)  is  complete — L  e.,  it  presents  four  calyces  (1,  1), 
pelvis  (2),  ureter  proper,  and  the  renal  artery  lying  on  the  ventral  sur- 
face of  the  calyces  and  pelvis.  The  calyces  and  pelvis  were  the  result 
of  corrosion  process.  Nos.  3  (left)  and  4  (right),  woman.  This 
pair  shows  well-marked  right  calyces  (1,  1),  Avell-developed  oval  pelvis 
(2),  and  distinctly  marked  right  narrow  proximal  isthmus  (3).     Promi- 

396 


THE  SHAPE   OF  THE   URETER. 


397 


nent  right  lumbar  spindle  (4).     The  right  middle  isthmus  (5)  should  be 
placed  on  a  level  with  the  left  middle  isthmus  (5). 

Two  pelvic  spindles  exist  in  each  ureter  (6,  6).  The  right  lumbar 
spindle  is  generally  larger  in  woman  than  man.  The  distal  isthmuses 
(7,  7)  were  larger  in  calibre  than  the  right  proximal  (3). 

Fig.  104. 


The  form  of  the  ureter.    (From  Byron  Robinson.) 

No.  5  (left),  lumbar  spindle  (4)  and  two  short  pelvic  spindles  (6,  6). 
No.  6  (right)  shows  short  narrow  proximal  isthmus  (3).  Two  large  and 
one  small  lumbar  spindle  (4),  narrow  middle  isthmus  (5),  a  short, 
well-marked  pelvic  spindle  (6).  Nos.  7  (left)  and  8  (right),  man,  aged 
forty-six  years.  This  pair  shows  moderately  developed  calyces  (1,  1), 
double-armed,  slightly  developed,  rounded  pelvis  (2,  2).     Marked,  but 


398  AFFECTIONS   OF  THE    URETERS. 

distally  located  proximal  isthmuses  (3,  3).  Short,  but  marked,  lumbar 
spindles  (4,  4).  Moderately  marked  middle  isthmus  (5,  5).  Two  un- 
equally sized  pelvic  spindles  on  each  side  (6,  6).  Distal  isthmuses  (7,  7) 
about  equal  in  lumen  to  the  proximal  (3,  3).  JSTos.  9  (left)  and  10  (right), 
woman,  aged  forty-nine  years.  This  pair  shows  moderately  developed 
flattened  right  pelvis  (2).  Indistinct,  elongated,  proximal,  ureteral  isth- 
muses (3,  3).  Slightly  developed  left  lumbar  spindle  (4),  but  more 
marked  right  one  (10).  The  middle  isthmus  is  but  slightly  marked  on 
left  (5),  on  the  right  more  marked.  The  right  (10)  shows  two  large  and 
one  small  pelvic  spindle  (6,  6).  The  left  ureter  (9)  shows  one  pelvic 
spindle  (6°).  The  distal  isthmuses  (7,  7)  are  less  in  calibre  than  the 
proximal. 

TRAUMATISMS. 

The  ureters  are  sometimes  injured  as  the  result  of  gunshot-  or  stab- 
wounds,  or  general  injuries ;  or  during  surgical  operations  they  may 
be  partially  or  completely  severed. 

Treatment. — If  a  diagnosis  can  be  made  (and  this  is  usually  a  dif- 
ficult task  unless  the  ureter  is  injured,  at  the  time  of  an  operation),  the 
opening  in  the  tube  may  be  closed  by  suture.  If,  on  the  other  hand, 
the  tube  is  more  or  less  completely  severed,  its  continuity  can  be  restored 
by  anastomosis  (van  Hook's  operation),  the  ureter  being  approached  and 
exposed  either  extraperitoneally  or  intraperitoneally,  according  to  the 
cause  of  the  injury  and  the  location  of  the  wound. 

URETERITIS. 

This  condition  may  be  caused  by  the  direct  upward  extension  of  dis- 
ease from  the  bladder,  or  downward  from  the  kidney  (cystitis,  tubercu- 
losis, pyelitis),  but  is  so  obscured  by  the  bladder  or  kidney  symptoms 
that  its  existence  is  rarely  recognized  and  its  treatment  is,  as  a  rule,  a 
matter  of  speculation. 

STRICTURE  OF  THE  URETER. 

This  condition  has  been  diagnosticated  and  treated  by  means  of 
ureteral  catheters  and  bougies  passed  from  below  upward  through  the 
ureteral  orifice  or  through  an  incision  into  the  continuity  of  the  tube. 

STONE  IN  THE  URETER. 

It  sometimes  happens  that  a  renal  calculus  becomes  impacted  in  the 
ureter ;  but,  as  a  rule,  after  a  sharp  attack  of  kidney  colic  the  stone 
enters  the  bladder,  where  it  remains  and  enlarges,  or  is  passed  by  the 
urethra  (see,  Fig.  105).  The  diagnosis  is  to  be  made  from  the  history 
of  the  acute  onset  of  kidney  colic,  followed  by  hydronephrosis  or  pyo- 


STONE  IN  THE   URETER.  399 

nephrosis  due  to  the  blocking  of  the  ureter  (see  Fig.  105).     Catheteriza- 
tion and  even  exploration  of  the  ureters  may  be  justifiable  in  some 

Fig.  105. 


Calculi  impacted  in  an  ureter  with  hydronephrosis. 


cases.     Abdominal  palpation  and  rectal  examination  will  be  of  aid,  as 
will  also  a  quantitative  and  qualitative  examination  of  the  urine. 

Treatment. — The  patient  should  be  put  in  a  hot  sitz-bath,  given 
rectal  injections  of  hot  saline  solution,  and  enough  morphine  hypoder- 
mically  to  relieve  pain.     If  urination  be  impossible  and  the  bladder  is 


400  AFFECTIONS   OF  THE   URETERS. 

distended,  these  conditions  must  be  relieved  by  aseptic  and  gentle  cath- 
eterization. 

When,  after  a  fair  trial,  palliative  treatment  fails  and  the  calculus 
becomes  permanently  lodged  in  the  ureter,  then,  and  only  then,  is  it 
time  to  think  of  operative  relief.  The  ureter  is  exposed  by  a  lumbar 
incision,  the  stone  located  and  removed  through  a  longitudinal  cut, 
which  can  be  left  open  or  closed  according  to  the  preference  of  the  sur- 
geon, and  the  wound  should  be  treated  on  general  surgical  principles, 
every  endeavor  being  made  to  prevent  ureteral  fistulse. 

DIAGNOSIS  OF  KIDNEY  CONDITIONS  AND  LESIONS  WITH. 
OUT  CATHETERIZATION  OF  THE  URETERS. 

Voelcker  and  Joseph  have  found  that  indigocarmine  is  excreted  by 
the  kidneys  with  sufficient  regularity  and  promptness  to  make  it  a  reli- 
able indicator  of  the  functional  efficiency  of  the  two  organs.  The  diffi- 
culties of  ureteral  catheterization  and  the  uncertainty  of  cryoscopy,  which 
is  the  determination  of  the  necessary  freezing-point  of  the  blood  and 
urine,  have  made  these  newer  functional  aids  in  diagnosis  of  renal  lesions 
more  theoretical  than  practical.  The  author's  method  accomplishes  the 
same  purposes  in  a  much  simpler  and  reliable  manner.  Indigocarmine 
has  many  advantages  over  methylene-blue,  which  has  previously  been 
employed  in  renal  work.  It  is  non-toxic,  is  excreted  only  by  the  kidney, 
and  does  not  suffer  change  in  its  passage  through  the  body.  Its  appear- 
ance in  the  urine  is  noted  within  a  very  short  time  after  its  administra- 
tion, reaches  a  maximum  in  thirty  minutes,  and  the  coloration  disappears 
within  ten  hours.  The  authors  inject  into  the  gluteal  muscles  4  c.c.  of  a 
warm  sterile  4  per  cent,  solution  of  indigocarmine  in  physiological  salt 
solution.  On  introducing  the  cystoscope  the  urine  is  seen  to  leave  the 
ureteral  openings  in  jets  of  blue-colored  fluid,  which  gradually  disperse 
like  puffs  of  smoke.  Not  only  is  the  finding  of  the  ureteral  orifices 
greatly  facilitated,  but  it  is  possible  to  determine  positively  the  existence 
of  two  secreting  kidneys,  and  to  estimate  the  actual  amount  of  func- 
tionating tissue  in  each  kidney,  and  the  relative  proportion  of  the  work 
done  by  each  as  indicated  by  the  comparative  size,  frequency,  and  force 
of  the  two  streams.  The  method  has  been  used  successfully  in  a  number 
of  cases  in  which  the  results  were  controlled  by  operation  or  autopsy 
and  its  value  demonstrated. 

CATHETERIZATION  OF  THE  URETERS. 

By  means  of  any  of  the  various  ureter  or  catheterizing  cystoscopes 
now  on  the  market  (see  Figs.  106  and  107)  a  skilful  operator  is  often 
enabled  to  locate  the  ureters  and  pass  a  delicate  catheter  into  their 


CATHETERIZATION  OF  THE   URETERS. 


401 


interior,  from  which   will  flow  the  normal  or  morbid   secretion  from 
either  one  or  both  kidneys. 

Fig.  107. 


Fig.  106. 


Caspar's  ureter  cystoscope. 


Brenner's  ureter  cystoscope. 


In  the  Brenner  cystoscope  the  catheter  emerges  from  the  convex  side 
of  the  instrument,  while  in  the  Albarran  Caspar  and  Nitze  instruments 
the  catheter  is  situated  on  its  upper  or  concave  side.  The  choice  of  an 
instrument  depends  upon  the  requirements  of  the  case  and  the  skill 
and  experience  of  the  surgeon  in  this  special  field  of  work. 

26 


402 


AFFECTIONS  OF  THE   URETERS. 


The  technique  of  the  operation  is  practically  the  same  as  for  simple 
cystoscopy  (see  page  391).  The  ureters  being  found,  first  one  and  then 
the  other  is  catheterized  with  a  woven-silk  catheter  of  about  No.  5 
French  scale  under  the  direct  vision  of  the  operator.  The  eye  of  the 
catheter  having  entered  the  ureter,  the  stylet  is  withdrawn.  Simple  as 
this  seems,  it  is  often  a  very  difficult  and  sometimes  impossible  task, 
especially  in  hypertrophied  conditions  of  the  prostate  and  in  an  irrita- 
ble and  contracted  bladder.  In  this  manner  it  is  possible  to  determine 
whether  blood,  pus,  or  tubercular  material  escapes  from  the  right  or 
left  kidney,  and  also  if  one  or  both  are  functionating  normally;  and 
whether  both  kidneys  are  present  (and  this  is  a  most  important  ques- 
tion when  nephrectomy  or  nephrotomy  is  contemplated).  Blocking  of 
the  ureter  from  the  stoppage  of  a  renal  stone  or  from  a  structural  con- 
dition can  also  be  determined  with  more  or  less  accuracy.  Catheteriza- 
tion of  the  ureters  is  at  best  a  very  delicate  procedure,  not  devoid  of 
danger,  and  should  only  be  employed  when  all  other  methods  of 
examination  have  been  exhausted,  and  by  one  who  is  competent  to  do 
such  work.  It  must  be  remembered  that  the  little  catheter  may  cause 
more  or  less  (sometimes  quite  severe,  as  is  shown  by  bleeding)  trau- 
matism of  the  ureteral  orifice  and  the  ureter  itself,  thus  a  suitable  soil 


Fig.  108. 


Harris  segregator 


for  infection  may  be  produced,  the  seeds  of  which  are  already  present 
in  the  diseased  bladder,  ureter,  or  kidney. 

Kelly's  dry  method  of  catheterizing  the  ureters  is  omitted,  as  being 
especially  applicable  to  the  female  and  as  not  having  had  as  yet  a  sufn- 


CATHETERIZATION  OF  THE   URETERS.  403 

cient  trial  in  male  subjects,  in  whom,  in  all  probability,  it  will  not  prove 
of  much  value  on  account  of  the  length  of  the  urethra. 

The  Harris  segregator  (see  Fig.  108),  for  collecting  the  urines  without 
catheterizing  the  ureters,  may  prove  of  great  value  in  certain  cases, 
but  our  experience  with  it  is  too  meagre  to  warrant  positive  conclusions. 
Its  introduction  and  retention  cause  considerable  pain  and  uneasiness : 
therefore  great  care  has  to  be  exercised  that  traumatism  to  the  bladder 
and  adjacent  structures  is  not  produced. 

The  latest  procedure  for  collecting  the  urine  separately  from  the  two 
uterers  is  advocated  by  Cathelin,  of  Paris,  and  has  been  indorsed  by 
many  surgeons. 

Cathelin's  urine  separator  (diviseur  vesical  gradue)  is  an 
extremely  simple  instrument,  and  one  that  can  be  used  by  almost 
any  operator  and  requires  but  little  technical  knowledge.  It  has  been 
well  described  and  endorsed  by  Vanderpoel.  It  consists  of  a  hollow 
tube  in  the  shape  of  a  lithotrite,  corresponding  to  No.  25  French.  In 
the  centre  of  this  tube  is  a  flat  piston,  to  the  end  of  which  is  attached 
a  membrane  which  separates  the  bladder  into  two  lateral  chambers. 
Upon  the  sides  of  the  tube  are  two  openings,  into  which,  and  through 
which,  pass  two  ureteral  catheters.  The  manipulation  of  the  instrument 
is  as  follows :  The  sterilization,  in  the  first  place,  can  be  done  by 
ordinary  boiling  of  everything  except  the  gum  silk  catheters,  which  are 
sterilized  by  formaldehyde.  After  sterilization  one  of  the  catheters- 
should  be  passed  through  the  canal  at  the  side  until  it  comes  to  the 
opening  at  the  other  end  ;  the  same  should  be  done  with  that  of  the 
opposite  side.  The  second  step  is  the  injection  of  a  few  drops  of  liquid 
through  the  catheters  to  determine  their  permeability.  Next  attach 
the  membrane  or  diaphragm  to  the  distal  end  of  the  instrument,  where  it 
fits  into  a  catch  on  the  end  of  the  piston,  and  is  fastened  by  means  of  a 
little  tack,  held  in  place  by  a  spring.  The  membrane  being  attached 
and  in  position,  it  should  be  oiled  with  sterilized  oil  or  lubrichondrin, 
and  then  the  piston  withdrawn  until  it  (the  membrane)  disappears 
within  the  shaft. 

The  preparation  of  the  patient  is  the  same  as  for  any  cystoscopic 
examination — that  is,  the  bladder  is  wrashed  out  with  one  of  the  various 
aseptic  solutions  at  our  disposal,  after  which  it  is  necessary  to  determine 
the  capacity  of  the  bladder  (that  is,  not  its  greatest  capacity,  but  the 
point  where  the  patient  first  desires  to  micturate).  The  instrument  has 
been  used  by  Cathelin  on  a  patient  who  had  a  capacity  of  about  18 
grammes,  and  was  kept  in  situ  for  fourteen  minutes.  This  is  the 
smallest  bladder  on  record  which  has  thus  been  treated.  The  instru- 
ment can  be  used  in  almost  any  sized  bladder,  but  in  extremely  large  or 
sacculated  ones    it    might    not   be    applicable.     After    determining    the 


404 


AFFECTIONS   OF  THE   URETERS. 


capacity  of  the  bladder,  inject  10  c.c.  of  sterile  fluid,  in  order  afterward 
to  start  siphonage.  The  instrument  is  then  passed  and  the  catheters 
introduced — i.  e.,  protruded  at  the  distal  end  into  the  sides  and  lower 
part  of  the  bladder.     The  distance  which  they  should  be  introduced  de- 


Ftg.  109. 


Cathelin's  urine  separator  (diviseur  vesical  gradue). 


pends  upon  the  capacity  of  the  bladder.  If  it  is  one  of  100  grammes, 
they  should  project  2  cm.;  if  200  grammes,  4  cm.;  if  300  grammes, 
6  cm.,  which  distance  can  be  measured  by  markings  on  their  proximal 
end.    After  introduction,  the  beak  of  the  instrument  is  brought  back  snugly 


CATHETERIZATION   OF  THE   URETERS. 


405 


Cathelin's  urine  separator  showing  the  development  of  the  dividing  membrane. 

against  the  symphysis  pubis,  which  brings  the  inferior  portion  with  part  of 
the  membrane  into  the  posterior  urethra,  so  that  part  of  the  membrane  lies 

Fig.  111. 


Showing  the  urine  separator  in  situ  with  the  membrane  expanded  and  the  mechanism  of 
collecting  the  urine  from  the  two  ureters. 

in  and  divides  the  posterior  urethra  as  it  does  the  bladder.  After  it 
is  drawn  against  the  symphysis  pubis,  protrude  the  membrane  corre- 
sponding to  the  number  of  grammes  which  the  bladder  will  hold,  which 


406  AFFECTIONS  OF  THE   URETERS. 

is  marked  upon  the  proximal  end  of  the  piston.  The  instrument  is  then 
brought  upward  slightly,  not  being  left  exactly  in  a  horizontal  position, 
so  that  the  membrane  will  fit  better  into  the  bladder  floor.  The  edge 
of  the  membrane  is  composed  of  a  thin  wire,  which  prevents  it  from 
collapsing.  The  fluid  which  has  been  injected  will  then  begin  to  flow 
easily  and  rapidly ;  but  if  the  streams  do  not  start  immediately,  it  is  a 
very  simple  matter  to  inject  a  few  drops  at  the  end  of  each  catheter, 
to  start  the  flow.  The  usual  sitting  is  not  over  thirty  minutes,  allowing 
eight  to  ten  minutes  for  getting  in  working  order.  The  urines  are  then 
collected  into  the  glasses  or  tubes,  the  outer  one  of  the  instrument 
being  held  firm  and  resting  on  a  stand  consisting  of  the  lid  of  the  box, 
into  which  is  secured  a  sliding  rod  for  male  or  female  patients.  The 
patient  is  prone  upon  the  table,  with  head  slightly  raised  and  thighs 
separated.  There  is  no  pushing  up  (as  in  the  segregator)  of  the  wall  of 
the  rectum,  and  no  forming  of  a  partition  in  the  bladder,  except  by  the 
membrane  which  is  introduced.  The  removal  is  simple.  First  with- 
draw the  catheters,  and  then  the  membrane,  after  which  release  the 
instrument  as  one  does  a  steel  sound. 


PLATE   XXI. 


ASCENDING    PYELONEPHRITIS,  CYSTITIS,   AND   HYPERTROPHY 
OF   THE    PROSTATE. 


PLATE  XXII. 


ASCENDING    PYELONEPHRITIS   AND   ABSCESS   OF    KIDNEY;   ENORMOUS 
VESICAL   CALCULUS   AND   CYSTITIS. 


CHAPTER   XX. 

AFFECTIONS    OF    THE    KIDNEY. 

SUPPURATIVE  INFLAMMATIONS  OF  THE  KIDNEY. 

The  suppurative  inflammations  of  the  kidney  may  be  classed  under 
the  following  heads :  pyelitis,  pyelonephritis,  pyonephrosis,  suppura- 
tive nephritis,  and  perinephritis. 

Pyelitis  and  Pyelonephritis. 

Pyelitis  is  a  condition  resulting  from  inflammation  of  the  pelvis  of 
the  kidney  and  of  its  calyces,  and  is  usually  accompanied  by  dilatation 
of  these  cavities.  It  should  be  clearly  borne  in  mind  that  in  only  a  few 
of  the  cases  under  consideration  is  there,  strictly  speaking,  the  definite 
morbid  entity  which  we  call  pyelitis.  In  some  cases  of  temporary 
irritation  and  inflammation  of  the  tissues  of  the  pelvis  and  the  calyces 
from  local  and  general  causes  these  structures  alone  are  involved ; 
but  in  the  great  majority  of  cases  the  morbid  process  extends  beyond 
the  pelvic  region  and  invades  the  parenchyma  of  the  kidney  proper  in 
various  degrees  of  extent  and  intensity.  In  nearly  all  cases,  therefore, 
in  which  the  causes  and  conditions  now  to  be  mentioned  result  in  dis- 
ease of  the  pelvis  of  the  kidney,  there  are  morbid  changes  in  the  renal 
parenchyma,  the  simplest  forms  of  which  are  acute  and  chronic  hyper- 
emia and  congestion  (which  may  or  may  not  be  of  ephemeral  duration), 
and  the  severe  ones  are  the  various  infiltrative  and  degenerative  changes 
now  to  be  mentioned.  In  all  forms  of  pyelitis  and  pyelonephritis  it  is 
very  probable  that  morbid  disturbances  of  a  congestive  nature  are  the 
predisposing  causes  which  underlie  the  conditions  of  susceptibility  to  the 
inflammation.  The  usual  exciting  causes  are  germ  infections.  Tissue- 
peculiarities  seem  to  render  some  individuals  more  susceptible  than 
others. 

Etiology. — Pyelitis  and  pyelonephritis  may  be  due  to  extension  of 
the  morbid  inflammatory  process  from  the  bladder  through  the  ureters 
(which  are  also,  as  a  rule,  involved),  as  a  result  of  stricture  of  the 
urethra,  hypertrophy  of  the  prostate,  the  various  forms  of  cystitis,  and 
of  atony  and  paralysis  of  the  bladder.  This  is  called  ascending  pyelitis 
and  pyelonephritis,  and  is  the  most  common  form  of  the  affection.  (See 
Plates  XXI.  and  XXII.) 

Ascending  pyelitis  and  pyelonephritis  may  also  result  from  ob- 
struction of  a  ureter  by  a  calculus.     Cases  have  recently  been  reported 

407 


408  AFFECTIONS  OF  THE  KIDNEY. 

in  which  pressure  upon  the  ureter  by  a  tumor  or  an  enlarged  uterus 
produced  suppuration  in  the  kidney,  probably  from  infection  from  the 
intestinal  canal.  Recent  observations  prove  that  in  exceptional  in- 
stances gonorrhceal  inflammation  may  attack  the  bladder,  travel  up  the 
ureters,  and  involve  both  the  pelvis  and  the  kidney.  In  some  cases 
the  infecting  agent  is  the  gonococcus,  but  in  other  cases  a  mixed  infec- 
tion is  the  cause  of  the  trouble. 

This  condition  may  be  unilateral  or  both  kidneys   may  be  attacked. 

Descending  pyelitis  and  pyelonephritis  are  that  form  in  which 
microbic  infection  seems  to  be  the  predominant  element,  and  which  is 
carried  to  the  kidneys  by  means  of  the  arterial  supply  and  the  veins, 
and  probably  by  the  lymphatics. 

These  cases  are  caused  by  various  acute  and  chronic  infectious  dis- 
eases, such  as  osteomyelitis,  caries  of  bones,  diphtheria,  typhoid  fever, 
appendicitis,  pyaemia,  puerperal  septicaemia,  perityphlitis,  and  lesions 
of  the  intestinal  canal,  liver,  and  spleen.  In  most  cases  these  condi- 
tions primarily  produce  nephritis,  and  the  resulting  pyelitis  is  due  to 
extension  of  the  morbid  process  by  contiguity  of  tissue  with  the  infect- 
ing foci.  It  is,  therefore,  in  such  instances  a  secondary  pyelitis.  But 
in  some  cases  there  has  been  found  an  antecedent  pyelitis  due  to  local 
lesions,  and  in  that  event  general  infective  processes  have  produced  an 
intense  form  of  the  pelvic  inflammation. 

Descending  pyelitis  and  pyelonephritis  may  therefore  be  of  the 
simple  catarrhal  or  the  suppurative  type. 

The  third  and  strictly  local  form  of  pyelitis  and  pyelonephritis  is 
that  caused  by  the  lodgement  of  sand,  gravel,  and  calculi  (uric  acid, 
oxalate  of  lime,  phosphates,  cystin,  and  xanthin),  and  is  called  calcu- 
lous pyelitis  and  pyelonephritis  and  nephrolithiasis,  and  is  due  either  to 
irritation  of  the  pelvic  tissue  itself  or  to  obstruction  of  the  ureter.  This 
condition  is  more  frequent  in  men  than  in  women.  In  some  cases  of 
highly  acid  urine  with  excess  of  uric  acid  crystals  and  of  oxalate  of 
lime,  a  superficial  pyelitis  may  be  produced  which  ceases  when  the 
irritating  cause  is  removed  ;  or,  if  the  latter  is  persistent,  the  pelvic 
inflammation  may  become  severe  and  ehronic,  and  then  the  renal  paren- 
chyma may  also  be  attacked.  Renal  calculi  may  be  small,  and  for  long 
periods  may  remain  in  the  pelvis  and  cause  no  symptoms.  In  many 
cases  they  lodge  in  the  ureter,  and,  if  not  too  large,  after  giving  rise  to 
considerable  pain,  may  pass  into  the  bladder.  In  some  cases  they  be- 
come impacted  in  the  ureter  and  cause  hydronephrosis  or  pyonephrosis. 
In  exceptional  cases,  when  these  conditions  are  unilateral  and  the 
other  kidney  is  diseased,  and  when  both  organs  are  thus  affected,  death 
usually  results  from  ursemia,  unless  operative  intervention  affords 
relief.     When  the  renal  calculus  remains    and  increases  in  size,  there 


PLATE  XXIII. 


PYELONEPHRITIS,   PERINEPHRITIC   ABSCESS,  AND 
CALCULI   OF    KIDNEY. 


PYELITIS  AND  PYELONEPHRITIS.  409 

may  be  mild  pyelitis,  and  severe  nephritis  or  intense  pyelonephritis 
may  be  produced.     (See  Plate  XXIII.) 

Pyelitis  and  pyelonephritis  may  result  from  traumatisms  of  the 
kidney  which  produce  perinephritis.  In  this  event  the  morbid  secre- 
tions burrow  and  rupture  into  the  pelvis  of  the  organ  or  into  the  renal 
parenchyma.  In  like  manner  foreign  bodies,  such  as  fragments  of 
bone,  benign  and  malignant  neoplasms,  or  parasitic  growths  near  the 
kidney,  may  lead  to  suppurative  degeneration  and  of  the  pelvic  and  renal 
parenchyma.  These  same  conditions  may  occur  around  or  near  the 
ureter,  which  then  becomes  blocked,  and,  as  a  result,  a  form  of  ascend- 
ing pyelonephritis  is  produced.  This  fourth  form  of  pyelonephritis 
really  belongs  in  the  category  of  traumatisms. 

The  fifth  form  of  pyelitis,  and  perhaps  pyelonephritis,  are  usually  of 
a  mild  catarrhal  character,  and  are  caused  by  the  elimination  through 
the  kidneys  of  such  drugs  as  creasote,  chloroform,  carbolic  acid,  canthar- 
ides,  turpentine,  copaiba,  cubebs,  and  santalwood  oil,  which  have  been 
taken  into  the  stomach.  In  these  cases  there  may  be  a  concomitant 
congestive  nephritis.  With  cessation  of  the  irritating  cause  the  kidney 
lesions  soon  undergo  resolution. 

Tuberculosis  is  a  rather  infrequent  cause  of  pyelitis  and  pyelo- 
nephritis, and,  while  it  may  arise  primarily  in  the  kidney,  it  is  very 
often  coexistent  with  and  perhaps  an  extension  of  the  same  process  in 
the  ureters,  bladder,  prostate,  seminal  vesicles,  testicles,  ovaries,  and 
uterus.  This  morbid  process  usually  begins  in  the  mucous  membrane 
of  the  pelvis  and  calyces,  and  thence  extends  to  the  stroma  of  the 
organs.  As  a  result,  the  tissues  are  degenerated  and  replaced  by  pulpy 
masses,  which  become  cheesy  and  calcified,  and  also  may  develop  into 
fibrous  tissue.     In  this  way  the  whole  organ  may  be  destroyed. 

Tubercular  nephritis  and  pyelonephritis  may  be  unilateral  and  com- 
plicated with  a  similar  process  in  the  urinary  tract  of  the  same  side. 
Extension  of  the  infiltration  may  lead  to  peritonitis  "and  pulmonary 
tuberculosis. 

Renal  tuberculosis  usually  occurs  about  puberty7fttit  may  manifest 
itself  beyond  the  fiftieth  year,  and  is  more  frequent  in  the  male  than 
the  female. 

There  is  also  an  ascending  and  usually  bilateral  form  of  tubercular 
pyeloaephritis  which  is  due  to  extension  from  the  prostate,  testes, 
seminal  vesicles,,  bladder,  and  ureters.  The  descending  form,  which  may 
be  unilateral,  is  due  to  infection  carried  through  the  bloodvessels  from 
foci  in  various  organs  of  the  body.  Primary  renal  tuberculosis  is  rare, 
but  instances  have  been  observed. 

In  tubercular  nephritis  and  pyelonephritis  the  morbid  process  may 
extend  through  the  capsule  and  attack  the  surrounding  fatty  and  con- 


410  AFFECTIONS   OF  THE  KIDNEY. 

nective  tissues.  This  tubercular  perinephritis  may  also  be  caused  by 
the  bursting  of  infected  cysts  seated  in  the  renal  parenchyma. 

Pathology  of  Pyelitis. — The  pelvis  and  calyces  become  dilated, 
their  mucous  membrane  thickened,  and  their  stroma  infiltrated  with 
cells.  The  epithelial  surface  becomes  covered  with  pus  and  mucus, 
and  in  some  places  it  is  thinned  and  in  others  thickened.  Calculi  and 
gravel  of  uric  acid  and  oxalate  of  lime,  and,  later  on,  phosphatic  con- 
cretions, may  also  be  present  in  these  parts.  In  very  ephemeral  cases 
in  which  the  irritation  or  inflammation  has  not  been  long  continued  or 
severe,  the  renal  parenchyma  may  not  be  invaded ;  but  in  most  in- 
stances there  is  hyperemia  of  varying  grades  of  intensity,  which  may 
lead  to  connective-tissue  infiltration  of  the  stroma  of  the  pyramids  and 
cortex,  degeneration  of  the  epithelium,  and  atrophy  of  the  glomeruli. 
In  severe  and  chronic  cases  there  may  be  true  suppurative  inflamma- 
tion, in  which  event  there  is  a  true  pyelonephritis. 

Pathology  of  Pyelonephritis. — In  ascending  pyelonephritis  one 
or  both  kidneys  may  become  much  congested  and  inflamed,  and  the 
pelvis  coated  with  pus  and  fibrin.  The  renal  parenchyma  becomes 
swollen  and  studded  with  foci  of  pus.  The  larger  of  these  foci  are 
enclosed  in  areas  of  hyperemia,  and  appear  as  white  streaks  or  lines 
in  the  course  of  the  tubes.  In  more  advanced  forms  abscesses  are  scat- 
tered throughout  the  organs,  which  are  very  much  congested.  The  very 
small  foci  can  be  seen  only  by  means  of  the  microscope,  which  reveals 
groups  of  pus-cells  between  the  tubes,  the  lining  epithelium  of  which 
is  degenerated. 

In  most  cases  of  pyelonephritis  the  walls  of  the  ureters  are  in- 
flamed and  thickened,  and  they  may  contain  pus  or  fibrin. 

In  descending  pyelonephritis  the  kidneys  become  much  enlarged, 
and  present  foci  of  suppurative  inflammation  resembling  little  white  spots 
surrounded  by  areas  of  hypersemic  tissue.  These  spots  consist  of  ag- 
gregations of  pus-cells  seated  between  the  tubes,  and  they  may  lead  to 
degeneration  and  necrosis  of  the  renal  parenchyma.  These  cases  are 
instances  of  microbic  infection  and  suppuration,  which  usually  involve 
the  pelvis  of  the  kidney. 

In  the  early  stage  of  calculous  pyelitis  there  may,  as  we  have 
already  seen,  be  but  little  change  in  the  pelvis  and  calyces  beyond 
mild  hypersemia  of  the  mucous  membrane.  Later  on,  should  the  irritat- 
ing cause  persist,  the  mucous  membrane  of  the  parts  may  become  thick- 
ened, their  stroma  infiltrated  with  cells,  and  their  surface  studded  with 
tissue-exudates.  From  the  inflammatory  focus  the  kidneys  may  be 
attacked  by  chronic  diffuse  nephritis,  in  which  there  is  hyperplasia  of 
the  connective  tissue  of  the  cortex  ;  the  cortex  tubes  are  atrophied  in 
some  parts  and  dilated  in  others,  and  they  contain  exudates,  casts,  and 


PYELITIS  AND  PYELONEPHRITIS.  411 

blood.  The  renal  epithelium  is  swollen  and  degenerated.  The  cells 
of  the  glomeruli  and  their  capillaries  are  at  first  increased  in  number, 
but  they  become  atrophied  later  on.  The  kidneys  are  usually  enlarged 
and  either  smooth  or  nodular,  and  they  are  variously  designated  as 
chronic  parenchymatous  nephritis,  waxy  kidney,  the  large  white  kidney, 
or  chronic  Bright' s  disease. 

In  pyelonephritis  resulting  from  traumatism  and  perinephritis 
there  is  much  degeneration  of  the  organs,  which  become  broken  down 
and  infiltrated  with  pus  and  blood. 

In  tubercular  pyelonephritis  the  lesion  usually  begins  in  the  mucous 
membrane  of  the  pelves  and  calyces,  and  thence  extends  to  the 
parenchyma,  which  becomes  degenerated  or  converted  into  fibrous  tissue 
infiltrated  with  pus.  In  some  cases  cheesy  and  calcareous  degeneration 
may  occur. 

The  various  micro-organisms  which  cause  renal  suppuration  are  the 
Bacterium  coli  commune,  the  staphylococci,  the  streptococci,  the  pro- 
teus  of  Hauser,  the  gonococci  alone  or  in  combination  with  pyogenic 
microbes,  and  the  Bacillus  tuberculosis. 

Chronic  pyelonephritis  may  affect  only  one  kidney  or  it  may  attack 
both.  In  some  rare  cases  in  which  but  one  kidney  is  thus  involved 
the  organ  previously  unaffected  becomes  sympathetically  involved,  even 
when  the  primarily  diseased  organ  has  been  adequately  drained.  The 
pathogenesis  of  this  complication  has  not  been  determined. 

Symptoms  of  Acute  and  Chronic  Pyelitis  and  Pyelonephritis. — 
Acute  pyelitis  is  rather  rare,  and  usually  is  produced  by  gravel  and  cal- 
culi and  by  the  irritation  of  various  drugs  taken  into  the  system.  The 
symptoms  may  be  so  mild  that  only  moderate  pain  in  the  loins  and  fre- 
quent micturition  are  complained  of;  but  in  some  cases  the  invasion 
is  sudden,  and  the  patient  suffers  from  headaches,  chills  and  fever, 
sweating,  nausea,  and  debility.  There  are  pain  in  the  loins,  frequency 
of  urination,  and  decided  tenderness  on  manual  pressure  over  the  kid- 
neys or  on  deep  respiration.  The  urine  is  rather  scanty,  loaded  with 
mucus  and  pus,  albuminous  from  presence  of  blood,  and  may  contain 
epithelial  cells  from  the  renal  pelvis.  There  may  be  reflected  pain  in 
the  penis  and  testicle.     The  kidneys,  as  a  rule,  are  not  much  enlarged. 

In  chronic  pyelitis  of  local  origin  long  periods  may  elapse  without 
the  appearance  of  appreciable  symptoms.  When  a  decidedly  purulent 
stage  is  reached  and  renal  disorganization  has  set  in  the  symptoms  are 
well  marked.  The  pain  in  the  loins  is  more  severe  and  constant  than 
in  the  lighter  form  and  the  changes  in  the  urine  more  marked.  At 
this  time  there  is  nephritis  as  well  as  pyelitis.  There  may  or  may  not 
be  polyuria,  but  the  amount  of  pus  present  is  decidedly  increased. 
As  a  result,  the  urine  is  albuminous,  which  condition   is  intensified  by 


412  AFFECTIONS   OF  THE  KIDNEY, 

the  addition  of  mucus  and  blood.  By  the  microscope  we  find  epithe- 
lial cells  from  the  pelvis  and  the  tubules  of  the  kidney.  Hyaline  casts 
and  pus-cylinders  may  also  be  discovered.  In  some  cases  the  amount 
of  blood  which  escapes  is  small,  in  others,  it  is  very  copious,  while 
in  a  few  it  may  be  absent.  Variations  in  the  amount  of  pus  and 
blood  secreted  may  be  observed  from  day  to  day. 

When  the  ureter  is  pervious  and  the  secretion  drains  off  thoroughly, 
the  urine  usually  remains  acid,  and  a  diagnosis  of  cystitis  is  not  to  be 
considered.  But  when  calculi  or  tissue-detritus  more  or  less  effectually 
blocks  a  ureter  (or  both  ureters)  ammoniacal  decomposition  occurs,  and 
it  then  becomes  difficult  to  determine  the  seat  of  the  trouble. 

The  unilateral  and  bilateral  nephralgic  pain  and  soreness  may  be 
constant  or  intermittent,  and  is  aggravated  on  deep  inspiration,  and  by 
jarring  and  sudden  movements  of  the  body  and  by  manual  pressure. 

The  kidney  will  be  found,  in  some  cases  early  and  in  others  quite 
late,  to  be  so  greatly  enlarged  that  the  swelling  can  be  recognized  by 
the  eye,  particularly  in  thin  subjects  and  when  there  is  a  complicating 
perinephritis. 

Bimanual  palpation  should  be  thoroughly  practised  when  these 
conditions  are  present.  The  patient  is  placed  on  his  back,  with  head 
and  shoulders  slightly  elevated  so  as  to  relax  the  abdominal  muscles, 
and  the  thighs  should  be  slightly  flexed  on  the  trunk.  Deep  pressure 
is  made  by  placing  the  fingers  of  one  hand  on  the  anterior  abdominal 
wall,  and  the  fingers  of  the  other  on  the  posterior  abdominal  wall,  be- 
tween the  last  rib  and  the  iliac  crest.  This  method  is  of  little  or  no 
value  in  fat  subjects  or  when  the  muscles  are  rigid  and  fixed.  General 
.anaesthesia  overcomes  muscular  rigidity.  It  is  often  of  value  in  thin 
subjects,  in  floating  and  movable  kidney,  and  when  the  kidney  is 
enlarged,  tender,  or  sensitive  from  any  cause,  viz.,  distention  of  its 
pelvis,  malignant  growths,  etc.  A  distended  colon  may  make  the 
examination  more  difficult  and  incomplete. 

With  the  intensification  of  the  renal  lesions  and  the  increase  in  the 
suppuration  the  patient's  health  fails,  and  he  becomes  thin,  anaemic,  and 
exhausted.  He  loses  appetite  and  suffers  from  chills  and  fever.  Unless 
he  is  relieved  by  surgical  intervention,  death  ensues  sooner  or  later. 

It  is  difficult  to  determine  the  time  of  invasion  in  ascending  pyelo- 
nephritis, for  the  reason  that  the  symptoms  are  masked  by  those  which 
have  previously  existed  in  the  ureters,  bladder,  prostate,  and  seminal 
vesicles.  In  these  cases  the  predominating  condition  is  the  antecedent 
cystitis,  in  which  the  symptoms  are  very  similar  to  those  produced  by 
the  renal  lesions.  In  all  cases,  as  a  rule,  by  a  careful  microscopic 
study  of  the  urine,  the  condition  of  the  kidneys  and  the  bladder  may 
be  ascertained,  so  long  as  that  fluid  remains  acid ;  but  when  ammo- 


PYELITIS  AND  PYELONEPHRITIS.  413 

niacal  decomposition  has  taken  place,  either  in  the  pelvis  of  the  kidney 
or  in  the  bladder,  or  in  both,  the  condition  of  the  urine  does  not  furnish 
precise  data.  In  many  cases  the  existence  of  ascending  pyelonephritis 
is  only  determined  with  certainty  at  the  autopsy.  In  all  cases  it  is 
important  that  palpation  of  the  kidney  should  be  thoroughly  practised, 
and  in  many  it  will  give  evidence  of  the  existence  of  an  enlarged  and 
painful  kidney.  With  the  upward  extension  of  the  morbid  processes 
from  the  bladder  and  ureters  there  is  very  often  an  intensification  of  the 
patient's  symptoms,  as  shown  by  the  increasing  deterioration  of  the 
patient's  health  and  strength,  in  the  progressive  emaciation,  and  in  the 
chills  and  fever,  dry  tongue,  rapid  pulse,  and  general  febrile  phenomena. 
In  these  cases  the  fatal  termination  is  due  to  ansemia  and  septicaemia. 

The  symptoms  of  descending  pyelonephritis  due  to  infectious  dis- 
ease are  for  a  time  obscured  by  general  morbid  conditions.  There  may 
be  renal  tenderness  and  pain,  and  enlargement  of  the  organ  may  per- 
haps be  made  out.  Frequent  micturition  and  the  passage  of  turbid 
urine  loaded  with  bacteria,  pus,  blood,  and  renal  tissue-elements  may 
call  attention  to  the  kidney  disorganization,  and  then  a  diagnosis  may 
be  made.  In  all  these  cases  the  dominating  symptoms  are  those  due  to 
general  blood-changes  caused  by  micro-organisms. 

The  symptoms  of  pyelonephritis  due  to  traumatisms  are  usually 
more  or  less  severe  pain  in  the  loin,  swelling  and  tenderness  in  the  kid- 
ney, together  with  chills  and  fever  and  gradual  emaciation.  In  such 
cases  there  are  pyuria,  polyuria,  hematuria,  and  frequent  and  perhaps 
painful  micturition. 

What  may  be  termed  elimination-pyelitis  and  pyelonephritis,  in 
which  various  drugs  already  mentioned  (vide  supra)  are  taken  into 
the  stomach  and  pass  out  through  the  kidneys,  may  not  be  accompanied 
by  any  symptoms.  In  some  cases  a  mild  febrile  movement  and  pain  in 
the  kidney  may  be  observed.  Hsematuria,  pyuria,  and  bacteriuria  may 
be  ephemeral  conditions  in  these  cases,  which,  as  a  rule,  cease  when 
the  irritating  agent  is  eliminated. 

The  symptoms  of  renal  tuberculosis  are  at  first  rather  ill  defined, 
particularly  when  the  lesion  is  of  primary  development.  In  cases  of 
tuberculosis  of  the  intestines,  lungs,  and  viscera,  the  kidney  infection 
may  not  develop  till  a  later  period,  and  for  a  time  its  symptoms  may 
be  masked.  Involvement  of  the  kidney  is  attended  by  pain  in  the 
loins,  and  by  frequent  and  perhaps  painful  urination.  In  the  urine, 
blood,  pus,  tissue-detritus,  epithelium  of  the  pelvis,  and  renal  paren- 
chyma tubercle  bacilli  may  be  found.  If  operative  intervention  is  not 
practised,  or  if  the  patient  does  not  remove  to  a  suitable  climate,  the 
usual  symptoms  of  phthisis  will  be  observed — gradual  emaciation  and 
loss  of  weight,  hectic  fever,  and  night-sweats. 


414  AFFECTIONS  OF  THE  KIDNEY. 

When  tuberculosis  invades  the  kidney  by  extension  from  the  bladder 
and  ureter,  its  recognition  may  for  a  time  be  masked  by  the  symptoms 
caused  by  the  various  affections  of  the  genito-urinary  tract,  namely,  the 
seminal  vesicles,  prostate,  and  testicles  in  men,  and  the  uterus  and 
ovaries  in  women. 

The  quantity  of  blood  which  escapes  with  the  urine  in  renal  tu- 
berculosis is  variable.  It  may  be  small  in  amount,  or  it  may  be  very 
copious.  It  may  be  passed  in  small  quantities  during  the  day  or  in 
gushes.     In  many  cases  it  is  absent  for  longer  or  shorter  periods. 

In  all  cases  of  pyelonephritis,  it  is  important  that  both  kidneys 
should  be  carefully  examined  in  order  to  determine  whether  the  disease 
is  unilateral  or  bilateral.  To  this  end,  palpation  of  the  organ  should 
be  thoroughly  made,  and  ureteral  catheterization  and  Harris's  segre- 
gator  should  be  employed. 

Diagnosis. — In  general,  the  diagnosis  is  to  be  made  between 
ascending  and  descending  pyelitis  and  pyelonephritis.  The  symp- 
toms of  lumbar  pain  and  perhaps  of  tumor  point  to  the  kidney  as  the 
seat  of  the  affection,  and  a  careful  examination  of  the  urine  may  then 
clear  up  all  doubt.  In  addition,  catheterization  of  the  ureters  or  segre- 
gation of  the  urine  by  Harris's  method  may  be  of  much  value. 

In  many  of  the  ascending  cases  the  difficulty  in  diagnosis  will  occur 
in  the  coexistence  of  cystitis  and  pyelonephritis.  By  means  of  care- 
ful physical  examinations  and  a  scientific  study  of  the  condition  of 
the  urine  the  exact  state  of  affairs  may  be  learned.  As  a  rule,  so 
obvious  are  the  symptoms  of  calculous  pyelonephritis,  of  traumatism 
of  the  kidney,  and  of  descending  pyelonephritis,  by  a  study  of  the 
case  and  the  examination  of  the  urine,  that  a  clear  diagnosis  can  be 
generally  made.  The  diagnosis  of  tuberculosis  of  the  kidney  may  for 
a  time  present  some  difficulty,  but  the  study  of  the  local  symptoms  and 
the  microscopical  examination  of  the  urine,  together  with  catheteriza- 
tion of  the  ureters,  will  generally  clear  up  doubt.  In  many  cases  the 
loss  of  flesh  and  of  health  and  the  existence  of  tuberculous  processes  in 
the  body  in  general  will  point  to  tubercular  infection  as  the  source  of 
the  trouble. 

Treatment  of  Pyelitis. — Mild  cases  of  pyelitis  require  rest  in  bed, 
a  light  nutritious  diet,  with  perhaps  local  counterirritation  and  the  hot 
bath.  The  urine  should  be  rendered  bland,  non-irritating,  and  anti- 
septic by  proper  internal  medication  and  suitable  waters.  If  the  pain 
is  severe,  it  must  be  controlled  by  the  guarded  use  of  opium  or  mor- 
phine. The  radical  or  operative  treatment  will  be  indicated  by  the 
recognition  of  the  etiological  factor.  Operation  should  be  deferred, 
as  a  rule,  until  the  cessation  of  acute  symptoms.  If  pyelitis  is  due  to 
renal  calculi,  to  an   obstruction  in  the   ureter,  to  hypertrophy  of  the 


SUPPURATIVE  NEPHRITIS.  415 

prostate,  or  urethral  stricture,  these  irritating  and  obstructive  lesions 
must  be  removed  by  suitable  surgical  procedures. 

Treatment  of  Pyelonephritis.— These  patients  must  be  nourished 
by  a  liberal  and  carefully  selected  fluid  diet,  and  counterirritation  over 
the  kidney  by  cupping  and  hot  applications  should  be  employed.  The 
urine  must  be  kej)t  as  antiseptic  as  possible  by  the  administration  of 
full  doses  of  urotropin,  boric  acid,  or  boric  acid  and  salol.  Hot  rectal 
irrigations  of  normal  saline  solution  are  often  of  marked  benefit  in 
these  cases,  and  may  be  employed  once  or  twice  daily. 

Treatment  of  Tuberculous  Pyelonephritis.— These  cases  should 
be  removed  to  a  suitable  climate  and  receive  the  usual  constitutional 
treatment  for  general  tuberculosis,  care  being  taken  to  avoid  any- 
thing that  is  liable  to  cause  renal  congestion.  If  the  real  nature  of 
the  disease  is  recognized  sufficiently  early,  and  the  other  kidney  is 
functionating  normally,  some  benefit  may  result  from  nephrectomy, 
although  the  other  kidney  is,  as  a  rule,  sooner  or  later  attacked  by 
the  same  process.  Nephrectomy  being  out  of  the  question,  the  patient 
receives  antituberculous  treatment,  and,  should  pus  form,  it  must  be 
evacuated  by  a  lumbar  incision. 

Suppurative  Nephritis. 

As  a  rule,  it  may  be  stated  that  in  most  cases  of  suppurative 
nephritis  there  is  also  a  concomitant  and  perhaps  secondary  invasion 
of  the  pelvis,  so  that  they  are  in  reality  instances  of  pyelonephritis. 
In  some  cases,  however,  the  morbid  process  is  confined  to  the  renal 
parenchyma.  It  may  exist  in  the  form  of  localized  foci  or  in  a  diffuse 
form.  In  some  cases  traumatisms  by  incised  or  punctured  wounds, 
gunshot-wounds,  and  blows  and  falls  are  the  exciting  causes. 

During  the  course  of  malignant  endocarditis,  pyaemia,  and  general 
infectious  diseases  emboli  may  pass  through  the  renal  arteries  and 
produce  foci  of  suppuration  in  the  kidney-substance.  In  these  cases, 
as  a  rule,  the  existence  of  renal  lesions  is  masked  by  the  symptoms  of 
the  general  infectious  process.  Suppurative  nephritis  may  attack  one 
kidney,  or  both  may  be  involved. 

The  symptoms  arc  chills,  fever,  sweats,  and  vomiting.  There  are 
pain  in  the  loins,  suppression  of  urine,  and  an  advancing  typhoid  con- 
dition which  usually  terminates  fatally. 

Treatment. — In  the  majority  of  these  cases  little,  if  anything, 
can  be  done  except  in  a  medical  way ;  if,  however,  the  suppuration 
can  be  distinguished  as  a  localized  condition,  the  pus  can  sometimes  be 
evacuated  by  aspiration  or  by  an  exploratory  lumbar  incision.  Re- 
moval of  the  entire  kidney  may  appear  advisable  to  the  surgeon  when 
the  destruction  of  parenchyma  has  been  great. 


416  AFFECTIONS   OF  THE  KIDNEY. 

Perinephritis. 

This  condition  is  the  result  of  various  causes  which  result  in  sup- 
puration of  the  fatty  and  connective  tissues  seated  behind  the  kidney, 
which  tissues,  it  should  be  remembered,  surround  the  whole  organ.  In 
almost  all  cases  the  affection  is  due  to  suppurative  inflammation  which 
goes  on  to  abscess-formation,  hence  the  term  perinephritic  abscess  is 
used  by  some  authors.  But  it  should  be  borne  in  mind  that  in  some 
cases  of  chronic  nephritis  the  fatty  and  connective-tissue  envelope 
undergoes  synchronous  inflammation,  and  it  then  becomes  converted 
into  a  fibrous  capsule  which  is  developed  around  the  proper  kidney 
capsule.  This  cannot  be  considered  typical  perinephritis  as  generally 
understood.  Perinephritis  may  occur  in  a  primary  form  in  which  the 
suppuration  begins  in  the  post-renal  connective  tissue,  and  in  a  second- 
ary form,  in  which  suppuration  in  a  contiguous  part  burrows  behind 
the  kidney. 

The  secondary  form  of  perinephritis  is  the  one  more  commonly  en- 
countered, in  which  abscesses  or  infective  processes  by  extension  from 
the  gall-bladder,  spleen,  or  liver,  or  from  the  duodenum  and  intestine 
(chiefly  the  ascending  and  descending  colon),  or  from  the  vertebrae  and 
pelvic  bones,  from  the  appendix,  and  from  the  uterus  and  ovaries,  and 
very  rarely  from  the  lung  and  pleura,  invade  the  post-renal  connective 
and  fatty  tissue  envelope. 

The  primary  form  of  perinephritis  is  much  less  common,  and  is 
generally  caused  by  traumatism,  such  as  contusions  from  blows  and 
falls  upon  the  lumbar  region.  In  this  category  perhaps  may  be  classed 
cases  of  perinephritis  which  have  been  caused  by  infections  from  open 
wounds  in  the  integument  behind  the  kidney. 

It  is  not  uncommon  for  perinephritis  to  develop  from  extension  of 
the  inflammation  from  the  kidney  itself  in  cases  of  suppurative  neph- 
ritis, pyelitis,  pyelonephritis,  pyonephrosis,  hydronephrosis  (infected), 
and  ureteritis. 

Little  can  be  said  with  precision  as  to  the  cases  of  perinephritis 
which  have  been  termed  spontaneous,  and  said  to  be  due  to  a  depraved 
condition  of  the  system  and  exposure  to  cold  and  wet.  In  all  these  cases 
it  is  probable  that  the  nature  of  the  exciting  cause  was  not  made  out. 

When  suppuration  has  become  profuse,  extrusion  of  the  pus  may 
occur  from  the  abscess-cavity,  and  then  it  may  rupture  into  the  colon 
or  stomach  and  into  the  pleural  cavity.  It  may  also  burrow  within 
the  sheath  of  the  psoas  muscle,  and  open  either  under  Poupart's  liga- 
ment or  it  may  follow  the  iliac  vessels  into  the  femoral  region,  or  it 
may  pass  through  the  sacrosciatic  foramen  and  spread  to  the  gluteal 
region,  and  there  form  a  urinary  or  renal  fistula. 


PERINEPHRITIS.  417 

Symptoms. — The  symptoms  of  perinephritis  may  for  a  longer  or 
shorter  time  be  obscure.  It  can  be  readily  seen  that  in  all  cases  of  sup- 
puration in  the  gall-bladder,  spleen,  liver,  duodenum,  intestines,  and 
appendix,  and  of  destructive  diseases  of  the  vertebrae  and  sacrum,  and 
from  inflammations  of  the  uterus  and  lungs,  the  dominant  symptoms 
will  centre  in  these  various  affections,  and  that  the  perirenal  lesion 
mav  be  wholly  obscured  by  them,  until  the  perinephritis  is  sufficiently 
far  advanced  to  give  rise  to  demonstrable  lesions.  On  the  other  hand, 
when  the  affection  originates  in  traumatism,  such  as  blows  and  falls 
and  from  punctured  and  incised  wounds,  the  symptoms  are,  as  a  rule, 
promptly  apparent. 

The  most  constant  and  suggestive  symptom  is  pain  in  the  lumbar 
region  above  the  iliac  crest,  which  may  develop  slowly  or  promptly. 
If  the  patient  is  thin,  deep  pressure  over  the  abdomen  may  lead  to  the 
suspicion  of  commencing  perinephritic  abscess,  and  by  counterpressure 
over  the  loin  (bimanual  palpation)  further  information  may  be  gained. 
Very  soon  the  movements  of  the  trunk  and  leg  become  impaired  and 
are  attended  with  severe  pain.  This  may  so  increase  that  the  leg  be- 
comes flexed  upon  the  abdomen.  As  the  inflammatory  condition  be- 
comes more  severe,  locomotion  may  become  impossible,  and  the  thigh 
is  adducted  and  the  body  bent  forward.  Febrile  symptoms  promptly 
supervene,  being  mild  at  first,  and  severe  when  the  suppurative  process 
becomes  well  established.  Then  the  febrile  movement  may  be  very 
severe,  and  the  patient  may  suffer  from  chills,  rigors,  and  vomiting. 
If  the  pus  points  toward  the  lumbar  region,  a  red  brawny  tumor  slowly 
develops,  in  which,  later  on,  fluctuation  may  be  felt.  If  this  abscess 
opens  spontaneously,  or  if  it  is  incised,  the  severity  of  the  symptoms 
promptly  subsides ;  but  as  long  as  the  pus  is  walled  up  the  symptoms 
continue  severe. 

From  what  has  been  stated,  it  can  be  seen  that  the  salient  symptoms 
of  perinephritis  are  deep-seated  lumbar  pain,  increasing  difficulty  of 
movements  of  the  trunk  and  leg,  and  swelling  in  the  lumbar  region. 
AVhen  pus  burrows  in  the  directions  mentioned  a  multitude  of  inflam- 
matory and  painful  symptoms  is  developed,  and  a  correct  diagnosis 
can  only  be  made  by  an  intelligent  study  and  examination  of  the  case 
in  all  its  phases. 

Treatment. — Until  the  diagnosis  of  perinephritic  abscess  has  been 
definitely  made,  the  patient  should  receive  the  same  treatment  as  that 
directed  for  suppurative  renal  diseases.  When,  however,  abscess  forms, 
its  contents  must  be  freely  evacuated  by  a  lumbar  incision,  and  its 
cavity,  the  surrounding  tissues,  and  the  kidney  itself,  if  it  be  impli- 
cated, thoroughly  drained  with  tubes  and  gauze. 

27 


418  AFFECTIONS  OF  THE  KIDNEY. 

Pyonephrosis, 

As  a  result  of  chronic  pyelitis  and  pyelonephritis,  an  ureter  may  be 
obstructed,  in  which  event  the  pelvis  and  calyces  of  the  kidney  become 
greatly  dilated  and  contain  urine,  pus,  and  blood,  and  in  many  cases, 
in  addition,  tuberculous  material,  cancerous  masses,  diphtheritic  mem- 
branes, and  hydatids,  together  with  urates,  oxalate  of  lime,  and  carbon- 
ates and  phosphates  of  lime.  The  resulting  condition  is  called  pyo- 
nephrosis, in  which  there  is  an  elastic  and  perhaps  fluctuating  tumor 
of  varying  size  in  .the  loin  which  sometimes  projects  into  the  abdominal 
cavity.  In  some  cases  the  blocking  of  the  ureter  is  permanent,  and 
then  the  renal  tumor  may  become  very  large.  In  other  cases  there 
may  be  only  an  intermittent  blocking  of  the  ureter,  and  with  the  escape 
of  the  incarcerated  fluid  the  size  of  the  tumor  appreciably  lessens.  In 
all  cases  of  pyonephrosis  marked  structural  changes  take  place  in  the 
kidney.  The  pelvis  and  calyces  are  dilated,  and  the  papillae  are  flat- 
tened and  perhaps  obliterated.  As  the  process  extends,  the  pyramids 
and  the  cortex  of  the  kidney  become  atrophied  and  their  structure 
destroyed,  and  a  pouch-like  abscess-cavity  filled  with  pus,  tissue-detri- 
tus, and  inorganic  matter  is  produced. 

In  some  cases  pyonephrosis  is  the  outcome  of  hydronephrosis  com- 
plicated with  infection,  as  described  later  on. 

In  some  cases  of  pyonephrosis  drainage  of  the  abscess-cavity  may 
occur,  and  the  patient  may  not  experience  much  pain  or  discomfort ; 
but  in' others  the  pelvis  or  degenerated  renal  tissue  may  undergo  ulcera- 
tion and  rupture  occurs.  In  this  event  the  fluid  may  escape  into  the 
connective  tissue  around  or  behind  the  kidney,  or  into  the  iliac  fossa  and 
under  Poupart's  ligament ;  or  the  extravasation  may  occur  into  the 
lungs  and  bronchi,  into  the  bladder,  the  intestines,  or  even  into  the 
peritoneum.  In  some  cases  pyonephrosis  is  unilateral,  while  in  others 
both  kidneys  are  thus  attacked.  As  a  rule,  in  pyonephrosis  (as  well 
as  in  pyelonephritis)  there  is  a  concomitant  affection  of  other  parts  of 
the  urinary  tract. 

It  is  sometimes  observed  in  cases  of  pyonephrosis  that  the  activity 
of  the  disease-process  ceases  and  the  tumor  shrivels  up.  In  this  event 
the  purulent  fluid  becomes  inspissated,  and  a  putty-like  or  mortar-like 
material  is  produced.  In  these  cases  the  kidney  becomes  reduced  to  a 
small  fibrous  capsule,  which  may  undergo  calcareous  degeneration. 

Symptoms. — These  are,  in  the  main,  those  detailed  in  the  section  on 
pyelonephritis,  but  in  pyonephrosis  they  are  more  severe.  As  a  rule, 
the  tumor  is  larger  and  the  systemic  reaction  is  more  pronounced. 

Diagnosis. — The  presence  of  a  round,  perhaps  fluctuating,  some- 
what painful  tumor,  together  with  marked  pyrexia  and  intermittent 
pyuria,  points  in   most  cases   to  pyonephrosis  as   the  cause.     In  such 


HYDR  ONEPHB  OSIS.  419 

cases  a  careful  differential  diagnosis  should  be  made  between  the 
suppurative  condition  of  the  kidney,  and  fecal  impaction  of  the  colon, 
tumors  of  the  spleen,  liver,  and  gall-bladder,  and  from  cancer  and  tu- 
bercle of  the  kidney,  ovarian  cysts,  hydatid  cysts,  tumors  of  the  supra- 
renal bodies,  and  aortic  aneurism. 

Prognosis. — This  may  be  favorable  when  but  one  kidney  is  involved; 
but  when  both  organs  are  affected  it  is  unfavorable.  Cases  have  been 
reported  in  which  pyonephrosis  existed  for  months  and  years,  and  in 
which  the  symptoms  were  not  well  marked  and  the  patient's  health  was 
but  little  affected. 

Treatment. — We  may  try  to  remove  or  dislodge  the  obstruction  by 
having  the  patient  drink  freely  of  any  suitable  diuretic  water.  In  the 
event  of  failure  the  kidney  may  be  aspirated,  incised  (nephrotomy),  and 
drained,  and  the  ureter  examined  for  the  obstruction,  or  removed 
(nephrectomy),  according  to  the  state  of  the  opposite  organ  and  the 
patient's  general  condition.  For  a  description  of  these  operations  the 
reader  is  referred  to  the  section  on  operations  of  the  kidney,  in  which 
the  details  will  be  found  sufficiently  described. 

Hydronephrosis. 

Etiology. — This  condition  is  congenital  or  acquired,  and  is  either 
due  to  dilatation  of  the  pelvis  and  calyces  of  the  kidney  or  a  result  of 
an  obstruction  to  the  escape  of  urine  seated  in  the  urethra,  bladder,  or 
ureter.  In  general,  the  dilatation  is  limited  to  the  pelvis,  but  in  chronic 
cases  distention  of  the  kidney-substance  with  atrophy  is  observed,  to- 
gether, perhaps,  with  chronic  nephritis.  Hydronephrosis,  as  a  rule,  is 
unilateral,  and  exceptionally  both  kidneys  are  involved.  In  such  cases 
a  very  large  tumor  is  produced,  and  in  many  it  assumes  enormous  pro- 
portions. 

Congenital  hydronephrosis  may  be  due  to  stricture  of  the  urethra  or 
ureter,  or  to  malformation  and  duplieatures  of  the  mucous  membranes 
of  these  tubes.  In  some  cases  irregularities  in  the  course  of  the  ureters, 
looping  of  these  canals  and  their  abnormal  insertion  into  the  bladder- 
wall  are  the  cause  of  the  trouble.  Acquired  hydronephrosis  may  result 
from  movable  and  floating  kidney,  twisting  of  the  ureter  from  pelvic 
tumors  (chiefly  in  women),  a  temporarily  impacted  calculus,  or  from 
ureteral  obstruction  from  gravel. 

Symptoms. — These  are,  as  a  rule,  very  slight  at  first.  As  dilata- 
tion of  the  pelvis  increases  there  may  be  more  or  less  pain  and  a  dull, 
heavy  sensation  in  the  loin.  There  is  no  fever  except  in  cases  in  which 
suppuration  occurs,  and  then  a  pyonephrosis  is  produced.  In  many 
cases  hydronephrosis  is  intermittent,  due  to  the  escape  of  urine  at  inter- 
vals ;  after  such  escape   of  urine  the  tumor  is  temporarily  lessened  in 


420  AFFECTIONS  OF  THE  KIDNEY. 

size.  In  some  cases  the  development  of  hydronephrosis  is  very  rapid, 
and  then  pain  may  be  a  marked  symptom.  In  the  cases  in  which  the 
ureteral  obstruction  is  caused  by  an  impacted  calculus  or  by  gravel 
formation  there  may  be  attacks  of  vesical  colic  and  the  appearance  of 
blood  in  the  urine.  When  the  hydronephrotic  tumor  is  of  extremely 
large  size,  it  may  cause  much  pain  and  distress,  and  adhesions  may 
take  place  to  the  surrounding  structures. 

When  only  one  kidney  is  attacked  the  other  one,  as  a  rule,  under- 
goes compensatory  hypertrophy. 

Diagnosis. — The  presence  of  a  cyst-like  tumor  in  the  flank,  with  a 
sense  of  weight  and  some  pain  and  discomfort,  and  sometimes  the  co- 
existence of  renal  colic,  should  lead  to  a  suspicion  of  hydronephrosis. 
It  is  always  well  to  consider  the  existence  of  ovarian  cysts  and  intra- 
ligamental  cysts  being  mistaken  for  hydronephrosis.  In  many  cases 
aspiration  and  the  chemical  and  microscopical  examination  of  the  con- 
tained fluid  will  furnish  much  diagnostic  aid,  and  in  nearly  all  cathet- 
erization of  the  ureter  will  clear  up  doubts. 

Prognosis. — This  will  depend  upon  the  cause  of  the  affection.  If 
malformations  of  the  ureter  cause  hydronephrosis,  particularly  when 
double,  death  will  occur  unless  surgical  intervention  is  practised.  In 
unilateral  hydronephrosis  the  prognosis  is  usually  good,  but  when  it  is 
bilateral  it  may  lead  to  death.  When  hydronephrosis  develops  into 
pyelitis,  pyelonephritis,  and  pyonephrosis  the  outlook  is  very  serious. 

Treatment. — If  the  blocking  is  due  to  ureteral  obstruction,  that 
condition  must  be  remedied  by  exposing  the  ureter  and  removing  an 
impacted  stone,  or  straightening  out  a  kink,  or  twist  or  loop.  These 
conditions  not  being  present,  the  kidney  should  be  aspirated,  or  incised 
and  the  sac  drained,  or  the  entire  mass  removed  by  nephrectomy,  hav- 
ing first  ascertained  the  existence  and  condition  of  the  opposite  organ. 

STONE  IN   THE   KIDNEY. 

In  the  vast  majority  of  cases  renal  calculi  are  composed  of  uric 
acid  ;  but,  as  is  the  case  with  vesical  stone,  they  may  be  oxalic  or 
phosphatic,  and  very  rarely  are  made  up  of  cystine  or  xanthine,  their 
composition  depending  upon  the  patient's  diathesis.  The  stone  may 
consist  of  one  salt  or  of  many  varieties,  which  are  deposited  around 
the  nucleus,  depending  upon  the  chemical  composition  of  the  urine  at 
the  time  and  the  diseased  condition  of  the  kidney  or  its  pelvis. 

Calculi  originate  in  the  secretory  substance  of  the  kidney  or  its 
pelvis,  the  urinary  salts  being  deposited  on  a  nucleus  consisting  of 
minute  blood-clots,  shreds  of  tissure,  epithelial  cells,  or  mucus,  and  held 
together  by  a  peculiar  albuminoid  or  colloid  material  from  the  urinary 
tract  in  irritated  and  diseased  conditions. 


PLATE  XXIV. 


RENAL   CALCULUS. 


STONE  IN  THE  KIDNEY.  421 

Stones  may  be  single  and  large,  or  multiple  and  small ;  their  color,  con- 
sistence, and  appearance  depending  upon  their  chemical  composition.  They 
are  usually  found  in  the  pelvis  and  calyces  of  the  kidney  or  its  infun- 
dibula,  even  in  the  kidney-tissue  proper.  They  occur  more  frequently 
in  men  than  in  women,  and  in  those  who  lead  indoor  lives  without  suf- 
ficient exercise  in  the  open  air  and  sunshine.    (See  Plate  XXIV.) 

Symptoms. — The  symptoms  of  renal  stone  are  subject  to  many  varia- 
tions, depending  upon  the  degree  of  obstruction  the  stone  offers  to  the 
passage  of  urine  into  the  ureter,  and  also  upon  the  amount  of  irritation 
and  inflammation  it  produces  as  a  foreign  body  in  the  pelvis  of  the 
kidney.  Individuals  have  been  known  to  carry  stones  in  the  kidney 
for  many  years  without  being  aware  of  their  presence,  while  some 
surfer  intensely  and  at  short  intervals.  As  a  rule,  the  latter  patients 
complain  of  lumbar  pain,  extending  along  the  course  of  the  ureter  into 
the  testicle,  which  is  sometimes  forcibly  and  even  painfully  retracted. 
Attacks  of  renal  colic  coming  on  spontaneously  or  as  the  result  of  ex- 
ercise or  jolting  are  very  common,  and  are  associated  with  nausea, 
vomiting,  and  general  prostration ;  urination  becomes  frequent  and 
painful,  and  is  often  followed  by  vesical  and  rectal  tenesmus;  the 
amount  of  urine  is  decreased,  and,  unless  prompt  treatment  brings  re- 
lief, total  suppression  may  ensue. 

Hematuria  varies  greatly,  but  is  never  marked  except  after  a  sharp 
attack  of  colic,  when  the  urine  may  be  quite  bloody  or  even  contain  a 
few  small  clots.  These  patients  sometimes  pass  small  calculi  or  frag- 
ments of  stones  by  the  urethra  (see  Plate  XXIV.)  during  or  just  after 
the  attack.  The  amount  of  pus  in  the  urine  depends  upon  the  degree 
of  inflammation  in  the  kidney  or  its  pelvis,  and  is  therefore  variable. 

Diagnosis. — Stone  in  the  kidney  can  usually  be  diagnosticated  by  a 
careful  urinary  examination,  taken  in  connection  with  the  patient's 
history  and  present  condition.  On  palpation  the  kidney  region  is 
tender  and  tense,  and  in  very  thin  subjects  the  region  can  be  mapped 
out  and  sometimes  calculi  felt.  These  methods  failing  to  make  the 
diagnosis  clear,  the  kidney  should  be  exposed  by  lumbar  incision,  pal- 
pated with  the  finger,  and  explored  with  the  needle  ;  but  even  these 
procedures  sometimes  fail  to  detect  small  and  impacted  stones. 

Treatment. — The  treatment  is  palliative  or  radical,  depending  upon 
the  degree  of  stone-formation.  If  the  patient  is  passing  large  quan- 
tities of  crystals,  gravel,  or  sand,  the  diathesis  is  ascertained,  and  he 
should  be  put  on  appropriate  dietetic  and  medicinal  treatment  to  correct 
the  condition  of  the  urine,  and  the  kidneys  flushed  with  copious 
draughts  of  suitable  waters.  Attacks  of  acute  renal  colic  are  con- 
trolled by  the  hypodermic  use  of  morphine — sometimes  a  general 
anesthetic  is  required — and  the  hot  bath  ;  also,  hot  applications  over  the 


422  AFFECTIONS  OF  THE  KIDNEY. 

kidney  and  rectal  irrigations  of  hot  saline  solution.  When  the  stone 
is  impacted  in  the  kidney,  and  by  its  presence  threatens  suppuration, 
or  by  blocking  a  ureter  causes  hydronephrosis  or  pyonephrosis,  it 
should  be  removed  by  nephrolithotomy  and  the  kidney  drained,  if  sup- 
puration has  occurred  ;  otherwise  the  incision  may  be  closed  with 
sutures  if  deemed  advisable  by  the  surgeon. 

TUMORS    OF   THE   KIDNEY. 

New  growths,  or  tumors,  of  the  kidney  may  be  benign  or  malignant 
in  character.  The  former  are  of  little  clinical  importance,  as  they 
rarely  give  rise  to  serious  or  even  appreciable  manifestations. 

Among  benign  tumors  may  be  mentioned  papilloma  of  the  pelvis, 
and  fibroma,  adenoma,  and  lipoma  of  the  kidney-tissue  proper. 

The  commonest  and  most  important  malignant  tumors  of  the  kidney 
are  sarcomata  and  adenomata. 

Sarcomata  and  Adenomata, 

Sarcomata  may  arise  either  from  the  kidney  proper  or  its  pelvis, 
growing  slowly  in  some  cases  and  very  rapidly  in  others,  so  that  in  a 
short  time  the  mass  practically  fills  the  abdominal  cavity.  They  are 
most  frequently  encountered  in  young  children  and  infants,  but  are 
sometimes  met  with  during  adult  life. 

Adenomata  generally  spring  from  the  cortex  of  the  kidney,  and  in 
some  cases  remain  small  and  non-malignant,  while  in  others  they  grow 
rapidly,  become  very  vascular,  and  soon  degenerate  into  true  carcino- 
mata. 

Symptoms. — Malignant  growths  of  the  kidney  give  rise  to  a  hard 
lumbar  tumor,  which  soon  forms  adhesions  with  the  surrounding  struct- 
ures and  viscera,  thus  rendering  an  accurate  diagnosis  as  to  its  origin 
very  difficult  and  sometimes  impossible.  Pain,  which  is  constant  and 
severe  in  some  cases,  is  paroxysmal  or  absent  in  others.  Hematuria 
is  a  more  constant  symptom  ;  it  also  varies  in  amount  and  duration, 
being  sometimes  profuse  and  constant  and  followed  by  anaemia  and 
great  exhaustion,  and  again  slight  in  amount  and  intermittent,  coming 
on  spontaneously  or  after  exertion.  As  a  general  rule,  to  which  there 
are  some  exceptions,  these  patients  soon  lose  flesh  and  strength,  and 
become  very  anaemic  and  exhausted  ;  the  appetite  is  impaired  or  lost, 
and  they  suffer  from  gastro-intestinal  disturbances,  such  as  nausea  and 
vomiting. 

Treatment. — If  a  correct  diagnosis  has  been  made  at  an  early  date, 
and  before  adhesions  have  formed,  nephrectomy  should  be  performed  at 
once  if  the  opposite  organ  is  healthy  ;  if,  however,  the  disease  is  well 
advanced,  little  if   anything  can  be  gained  by  surgical  intervention, 


PLATE   XXV. 


CYSTS  OF   THE   KIDNEY. 


FLOATING   KIDNEY.  423 

In  such  cases  the  patient  should  be  made  comfortable  and  relieved  from 
pain. 

Cysts  of  the  Kidney. 

Cystic  disease  of  the  kidney  may  be  either  congenital  or  acquired. 

In  the  congenital  variety  the  kidney  is  greatly  enlarged,  being  made 
up  of  an  enormous  number  of  cysts,  while  its  tissue  proper  is  practi- 
cally absent.  The  cysts  vary  greatly  in  size,  and  contain  a  clear,  yel- 
lowish, brownish,  or  even  bloody  fluid  ;  they  are  lined  with  flat  epithe- 
lial cells,  and  consist  of  an  enlargement  of  the  tubules  and  capsules 
of  the  Malpighian  bodies.     (See  Plate  XXV.) 

In  the  acquired  variety  there  may  be  one  or  several  cysts  situated 
in  apparently  healthy  kidney-tissue,  which  does  not  seem  to  be  altered 
by  their  pressure,  unless  they  reach  large  proportions. 

Treatment. — If  the  cyst  is  large  enough  to  require  surgical  inter- 
vention, nephrotomy  and  drainage,  or  even  nephrectomy  (partial  or 
complete),  may  be  performed,  according  to  the  requirements  of  the  case, 
the  condition  of  the  opposite  organ,  and  the  judgment  and  experience 
of  the  surgeon. 

Hydatid  cysts  of  the  kidney  are,  as  a  rule,  very  rare,  and  when 
present  usually  attack  but  one  kidney,  and  are  then  associated  with  a 
similar  condition  in  other  organs  either  adjacent  or  remote.  They  may 
be  situated  in  any  part  of  the  kidney,  and,  although  usually  small  in 
size,  they  may  in  some  instances  reach  enormous  proportions.  Their 
treatment  is  the  same  as  that  just  given  for  simple  renal  cysts. 

FLOATING,   OR  MOVABLE,   KIDNEY. 

Although  attempts  have  been  made  to  establish  a  clear  distinction 
between  floating  and  movable  kidney,  it  is  best  to  use  the  terms  inter- 
changeably, as  the  exact  condition  is  only  seen  at  the  time  of  operation, 
and  the  treatment  is  the  same  for  both  conditions.  Strictly  speaking,  a 
movable  kidney  is  situated  behind  and  outside  of  the  peritoneal  cavity, 
whereas  a  floating  kidney  is  completely  invested  or  surrounded  by  a 
fold  of  peritoneum. 

Symptoms. — These  patients  suffer  from  acute  and  agonizing  attacks 
of  renal  pain,  coming  on  spontaneously  or  after  exertion.  The  pain  is 
sharp  and  cutting,  or  of  a  dull,  aching  character,  and  radiates  down  the 
loins  and  thighs.  The  parts  over  the  kidney  become  tense  and  painful 
on  manipulation,  by  which  means  the  kidney  can  be  recognized  as. a 
painful  and  movable  tumor.  In  some  cases  there  may  be  nausea  and 
vomiting. 

Treatment. — In  mild  cases  the  kidney  can  sometimes  be  kept  in 
position  and  the  attacks  prevented  by  wearing  body-bandages,  corsets, 


424  AFFECTIONS  OF  THE  KIDNEY. 

braces,  and  appliances,  and  avoiding  any  kind  of  exercise  that  is  liable 
to  bring  on  an  attack.  These  palliative  measures  failing,  the  kidney  is 
exposed  by  the  lumbar  incision,  returned  to  its  proper  position  and 
fixed  there  with  sutures  (nephrorrhaphy  or  nephropexy).  Should  this 
operation  be  unsuccessful,  the  case  urgently  demanding  it,  a  nephrectomy 
may  have  to  be  performed  for  the  patient's  comfort  .and  relief,  the  sur- 
geon always  having  ascertained  that  the  opposite  kidney  is  present  and 
functionating  normally,  which  can  be  done  by  cystoscopy,  catheterizing 
the  ureters,  or  collecting  the  different  urines  with  the  Harris  instrument. 

TRAUMATISMS   OF   THE   KIDNEY. 

The  kidneys  present  so  many  anomalies  in  the  distribution  of  their 
blood-supply,  and  in  their  size,  shape,  number,  and  position,  that  the 
surgeon  should  always  ascertain  the  presence  of  both  kidneys  before 
performing  a  radical  operation  on  one,  and  also  be  competent  to  cope 
with  an  anomalous  arrangement  of  bloodvessels  when  ligatures  during  a 
nephrectomy  are  applied.  The  presence  of  both  kidneys  can  be  ascer- 
tained by  palpation,  or,  this  failing,  by  cystoscopy,  either  with  or  with- 
out catheterization  of  the  ureters. 

Contusion  of  the  Kidney. 

Contusion  is -the  result  of  direct  violence  over  the  organ,  as  when 
patients  fall  upon  or  are  kicked,  hit,  or  injured  in  this  region.  The 
muscles  are  usually  in  a  more  or  less  relaxed  condition  at  the  time  of 
the  accident.     The  contusion  may  be  severe  or  trifling. 

Symptoms. — As  a  rule,  there  is  more  or  less  shock,  depending  upon 
the  nature  and  extent  of  the  injury.  This  is  followed  by  severe  renal 
pain,  extending  to  the  testicle,  which  may  be  retracted.  The  pain  is 
either  constant  or  intermittent,  and  may  be  accompanied  with  nausea 
and  vomiting.  Hematuria  is  absent,  slight  or  profuse,  depending  upon 
the  amount  of  damage  done    to  the  organ  by  the  traumatism. 

Treatment. — The  patient  is  kept  absolutely  quiet  in  bed  and  well 
under  the  influence  of  morphine.  Cold  applications  should  be  kept 
over  the  kidney,  and  ergot  administered  by  the  mouth  to  control  bleed- 
ing. A  firm  body-bandage  or  strip  of  rubber  plaster  applied  around 
the  body  will  aid  in  keeping  the  parts  at  rest.  The  patient  should  be 
nourished  by  the  rectum,  since  food  by  the  mouth  might  excite  nausea 
and  vomiting,  with  increased  bleeding.  Shock  is  treated  on  general 
surgical  principles.  If  urination  is  difficult,  the  patient  must  be  gently 
catheterized  to  prevent  straining  and  tenesmus.  Should  bleeding 
threaten  life,  an  exploratory  lumbar  incision  is  to  be  made,  and  the 
hemorrhage  controlled,  if  possible,  by  packing  the  wound  and  ligating 


OPERATIONS  ON  THE  KIDNEY.  425 

bleeding  points,  or,  this  failing,  the   surgeon  is  obliged    to    resort    to 
nephrectomy. 

Wounds  of  the  Kidney. 

Wounds  may  be  due  to  stabs,  cuts,  or  gunshot  injuries.  Their 
symptoms  are  in  general  the  same  as  those  of  contusion,  except  that 
bleeding  is  likely  to  be  more  severe  and  to  take  place  into  the  peritoneal 
cavity. 

Treatment. — The  wound  is  cleaned  and  packed  in  the  usual  manner, 
and  the  patient  given  the  same  treatment  as  that  just  described  for  con- 
tusion. If,  however,  the  hemorrhage  is  profuse  and  shows  no  tendency 
to  cease,  then  the  kidney  must  be  exposed  and  removed,  or  the  bleeding 
points  caught  and  tied  if  possible. 

OPERATIONS  ON  THE  KIDNEY. 

The  kidney  may  be  exposed  for  palpation,  needling,  incision,  or  ex- 
tirpation either  through  the  loin  or  the  anterior  abdominal  wall,  the 
former  being  the  safest  of  the  two  routes,  as  the  peritoneum  is  not 
opened,  the  kidney  lying  behind  it  in  the  perirenal  fat.  The  surgeon 
should  always  ascertain  the  existence  of  the  other  kidney  and  whether  it 
is  functionating  normally  before  undertaking  any  form  of  operative  inter- 
ference. The  abdominal  route  shows  the  existence  of  a  second  kidney, 
but  this  can  usually  be  determined  by  the  cystoscope,  ureteral  catheter, 
or  the  Harris  instrument,  or,  in  thin  subjects,  by  abdominal  palpation. 

Nephrotomy. — By  nephrotomy  is  meant  an  incision  into  the  kid- 
ney-tissue for  drainage  in  cases  of  renal  suppuration  or  hydronephrosis, 
or  for  exploration  of  the  kidney  and  its  pelvis  for  stone  or  other  abnor- 
mal conditions.  The  patient  is  placed  on  the  opposite  side,  with  a 
good-sized  sand-bag  pressing  into  the  flank,  so  as  to  increase  the  space 
between  the  last  rib  and  the  crest  of  the  ilium,  an  assistant  at  the  same 
time  forcing  the  kidney  up  into  the  loin  by  firm  pressure  on  the  anterior 
abdominal  wall. 

An  oblique  lumbar  incision  is  then  made  an  inch  below  the  last  rib, 
beginning  at  the  outer  border  of  the  erector  spina?  muscle  and  running 
forward  for  a  variable  (usually  from  four  to  six  inches)  distance,  de- 
pending upon  the  requirements  of  the  case,  care  being  taken  to  avoid 
the  pleura,  which  is  sometimes  quite  low  down  and  liable  to  injury  by 
the  knife,  or  tearing.  The  structures  are  carefully  divided  layer  by 
layer  and  the  vessels  caught  and  ligated  as  the  wound  is  enlarged,  in 
this  way  keeping  the  operative  field  dry,  which  is  extremely  important 
in  this  operation.  The  fatty  perirenal  capsule  having  been  exposed, 
is  gently  torn  through  and  the  kidney  exposed  and  brought  well  into 
the  wound,  whose  walls  are  retracted.     The   kidney  is   incised,  and 


426  AFFECTIONS  OF  THE  KIDNEY. 

explored  with  the  needle  or  finger,  and  if  pus  or  abnormal  contents  are 
found  they  are  evacuated  and  the  kidney  drained  with  strips  of  gauze 
or  a  good-sized  rubber  tube,  around  which  the  wound  is  tightly  packed, 
and  one  or  two  sutures  taken  at  each  angle.  If  no  abnormality  is  found 
at  the  exploratory  operation,  the  kidney  and  the  wound  should  be 
sutured,  care  being  taken  to  approximate  similar  muscles  and  structures 
with  accuracy. 

Nephrolithotomy. — Nephrolithotomy  consists  in  the  removal  of  cal- 
culi from  the  kidney  or  its  pelvis  by  means  of  the  oblique  lumbar  in- 
cision (nephrotomy)  described  above.  When  the  kidney  is  explored 
the  stone  is  sought  for  by  palpation  or  the  needle,  and  when  found, 
either  in  the  kidney  or  its  pelvis,  is  removed  through  an  incision 
by  long  forceps,  the  surgeon  always  being  careful  to  contuse  the  kidney- 
tissues  as  little  as  possible.  The  orifice  of  the  ureter  is  explored  to 
ascertain  if  it  is  patent ;  the  ureter  itself  is  also  examined.  The  incision 
into  the  pelvis  of  the  kidney  should  be  sutured  to  prevent  leakage  of 
urine  in  the  wound  and  the  formation  of  a  urinary  fistula.  The  kidney- 
tissue  can  also  be  sutured  or  left  open,  according  to  the  conditions 
found  and  the  requirements  of  the  case.  The  parietal  wound  is  drained 
with  a  large  rubber  tube,  around  which  is  packed  iodoform  gauze,  the 
angles  of  the  wound  being  approximated  by  sutures. 

Nephrectomy. — Nephrectomy,  or  total  removal  of  the  kidney,  is 
performed  either  through  the  loin  or  the  abdomen,  the  former  being  the 
usual  and  safer  route,  although  the  latter  may  have  to  be  employed  in 
some  cases. 

Lumbar  Nephrectomy. — The  kidney  having  been  explored  by 
the  lumbar  incision,  is  drawn  well  out  into  the  wound  and  freed  from 
all  surrounding  tissues.  The  vessels  and  ureter  are  then  separately  and 
carefully  ligatecl  and  divided  between  two  ligatures,  to  prevent  urine 
getting  into  the  wound,  which  should  be  drained,  packed,  and  partially 
sutured,  or  brought  together  by  buried  sutures,  as  the  surgeon  may 
decide,  although  it  is  far  better  to  rely  upon  drainage  for  the  first  few 
days. 

Abdominal  Nephrectomy. — In  this  operation  the  kidney  is  ex- 
posed and  removed  through  an  abdominal  incision  in  the  linea  semi- 
lunaris long  enough  to  allow  of  its  free  manipulation.  The  intestines 
are  held  aside  by  pads  of  sterilized  gauze,  the  kidney  enucleated,  and  its 
vessels  and  ureter  ligated  and  cut  between  two  ligatures,  as  in  the  lum- 
bar operation.  The  peritoneum  is  sutured  over  the  kidney-fat  and  the 
abdominal  wound  closed,  unless  there  is  some  contraindication.  Lum- 
bar drainage  should  be  instituted  if  deemed  necessarv  for  the  first  few 
days,  when  it  is  removed  and  the  wound  allowed  to  granulate  from  the 
bottom. 


NEPHORRHAPHY.  427 

Nephrorrhaphy,  or  Nephropexy. — The  kidney  is  exposed  by  a 
lumbar  incision  and  anchored  firmly  in  its  normal  position  by  passing 
several  silk  or  tmt  sutures  through  its  substance  and  then  through  the 
lumbar  fascia,  so  that  when  these  sutures  are  tied  the  kidney  rests  or  is 
held  snugly  against  the  abdominal  wall.  The  organ  is  freed  from  fat 
and  the  sutures  passed  directly  through  it  from  its  anterior  to  its  pos- 
terior surface,  and  just  inside  of  its  convex  border.  The  wound  may 
be  sutured,  or  left  open  and  drained.  Should  this  operation  be  unsuc- 
cessful, it  may  be  tried  a  second  time,  and  this  failing,  and  the  case 
urgently  demanding  it,  the  kidney  should  be  removed. 


CHAPTER    XXI. 

MISCELLANEOUS    AFFECTIONS    OF    THE    GEXITO-UMNARY 

SYSTEM. 

HEMATURIA. 

Strictly  speaking,  hematuria  (blood  in  the  urine)  is  merely  a 
symptom  of  many  diseased  or  abnormal  conditions  of  the  urinary  tract, 
and  is  not  a  morbid  entity  in  itself.  The  urine  may  be  only  tinged 
with  blood  or  it  may  contain  so  large  a  quantity  that  it  is  deep  red  and 
opaque.  The  blood  may  be  in  a  fluid  state  or  in  clots  of  various  shapes 
and  sizes,  depending  somewhat  on  the  origin  of  the  bleeding.  In  the 
majority  of  cases  bloody  urine  can  be  recognized  macroscopically,  but 
it  is  sometimes  necessary  to  make  a  microscopic  examination  to  dis- 
tinguish between  bloody  urine  and  urine  tinged  a  reddish  brown  from 
the  presence  of  haemoglobin  (hsemoglobinuria),  bile-pigment,  an  excess 
of  uric  acid,  or  such  drugs  as  rhubarb,  carbolic  acid,  or  senna,  which 
ingested  in  quantity  may  impart  a  bloody  hue  to  the  urine. 

The  hemorrhage  may  arise  from  the  anterior  urethra,  the  posterior 
urethra  (including  the  prostate  and  seminal  vesicles),  the  bladder,  the 
ureters,  or  the  kidney. 

If  there  is  oozing  of  a  bloodv  fluid  from  the  meatus,  and  if  the  first 
gush  of  urine  is  bloody  and  the  second  perfectly  clear,  it  is  safe  to  say 
that  the  bleeding  comes  from  the  anterior  urethra,  which  can  be  exam- 
ined by  the  endoscope  and  the  diseased  point  located.  "When  there  is 
practically  little  or  no  bleeding  from  the  meatus  and  both  the  first  and 
second  glasses  contain  bloody  urine  and  perhaps  small  irregular  clots, 
and  there  is  increased  frequency  of  urination,  with  perhaps  tenesmus  and 
the  passage  of  pure  blood  after  each  act,  we  are  warranted  in  suppos- 
ing that  the  blood  comes  from  the  deep  urethra,  prostate,  seminal  vesi- 
cles, or  neck  of  the  bladder.  A  rectal  examination  will  be  of  aid  in 
these  cases,  since  the  surgeon  can  palpate  the  base  of  the  bladder  and 
the  adjacent  structures. 

Hemorrhage  from  the  bladder-wall  does  not  necessarily  cause  in- 
creased  frequency  of  urination  unless  the  vesical  neck  be  involved.  In 
these  cases  the  urine  in  both  glasses  is  of  a  uniform  bloody  hue. 

If  the  bleeding  comes  from  the  ureter  or  kidney,  long,  worm-like 
clots  may  be  formed  in  the  ureter  and  passed  with  the  urine.  In  these 
cases  the  two-  or  three-glass  test  shows  blood  in  equal  amount  in  each 
glass.     Bleeding  from  these  parts  is   usually  preceded  or  followed  by 

428 


HEMATURIA.  429 

attacks  of  renal  colic,  and  lumbar  pain  shooting  down  the  ureter,  which 
latter  structure,  with  the  kidney,  is  sensitive  on  manipulation,  the  over- 
lying parts  being  tense  and  unyielding. 

If  the  hemorrhage  is  thought  to  come  from  the  bladder,  ureters,  or 
kidneys,  the  cystoscope  will  aid  the  examiner  greatly,  provided  the 
fluid  in  the  bladder  can  be  kept  fairly  clear  by  lavage  or  the  irrigating 
instrument.  If  the  bleeding  is  of  vesical  origin,  it  can  be  located  and 
seen  ;  and  if  from  the  kidney  or  ureter,  the  blood  will  be  seen  issuing 
in  little  jets  or  puffs  from  the  orifice  of  the  ureter,  provided  the  latter 
is  not  blocked  by  a  clot  or  stone. 

If  the  urine  is  so  bloody  that  the  cystoscope  cannot  be  used  satisfac- 
torily, a  very  useful  test  can  be  employed  to  locate  the  vesical  origin  of 
the  bleeding.  It  is  known  as  the  resorption  test,  and  its  action  depends 
upon  the  fact  that  the  vesical  mucous  membrane  has  no  power  of  ab- 
sorption except  under  diseased  or  abnormal  conditions.  The  technic 
of  the  procedure  is  as  follows :  the  bladder  is  irrigated  with  warm 
sterile  water,  all  of  which  is  allowed  to  run  out ;  it  is  then  filled  with  a 
1  to  2  per  cent,  solution  of  potassium  iodide,  and  in  fifteen  or  twenty 
minutes  the  saliva  is  tested  for  iodine  by  adding  the  patient's  sputum  to 
a  starch  solution,  which,  if  there  is  a  lesion  of  the  bladder  mucous 
membrane,  will  give  a  blue  color,  showing  absorption  by  the  diseased 
or  injured  bladder  mucous  membrane. 

In  all  cases  of  hsematuria  a  history  of  traumatism,  pain,  or  of  some 
local  distress  or  manifestation  must  be  closely  inquired  into  and  con- 
sidered by  the  physician  and  the  data  obtained,  will  be  found  of  the 
greatest  aid  in  establishing  a  correct  diagnosis  as  to  the  origin  of  the 
bleeding.  Thus,  traumatism  in  the  perineum  from  blows,  kicks,  or 
falls,  if  followed  by  bloody  urine,  either  with  or  without  bleeding  from 
the  meatus,  always  indicates  contusion,  laceration,  or  rupture  of  the 
urethra. 

Wounds  or  traumatisms  in  the  region  of  the  bladder,  ureter,  or  kid- 
ney, if  followed  by  bleeding,  always  point  to  the  seat  of  injury  and  the 
source  of  the  blood,  especially  if  the  patient  has  increased  frequency  of 
urination  with  tenesmus  or  attacks  of  renal  colic. 

Treatment. — The  source  of  the  bleeding  must  be  first  ascertained, 
and  the  cause,  if  possible,  removed  by  suitable  medical  or  surgical  pro- 
cedures. Patients  suffering  from  hsematuria  should  be  kept  very  quiet, 
and,  if  indicated,  given  ergot  or  gallic  acid  by  the  mouth  ;  and  if  pain 
be  present,  enough  opium  to  relieve  it  and  keep  them  quiet.  The  local 
and  operative  treatment  for  hsematuria  will  be  found  fully  described  in 
the  chapters  devoted  to  the  affections  of  the  urethra,  prostate,  ureters, 
and  kidneys,  and  are  therefore  not  repeated  here,  as  hsematuria  is 
merely  a  symptom  of  traumatic  or  morbid  conditions  of  these  organs. 


430  AFFECTIONS  OF  THE   GENITO- URINARY  SYSTEM. 

BACTERIURIA. 

There  is  a  very  prevalent  opinion  that  the  urine  of  individuals  not 
suffering;  from  disease  or  presenting  any  morbid  symptoms  is  always 
free  from  microbic  admixture  when  in  the  bladder.  It  is  now  well 
known  that  the  secretion  may  in  passing  through  the  urethra  carry 
with  it  some  or  many  of  the  usually  harmless  microbes  which  are  con- 
stantly present  in  that  canal.  Recent  observations,  however,  clearly 
show  that  the  urine  when  in  the  bladder  may  contain  many  micro-organ- 
isms, some  of  which  under  favorable  circumstances  may  become  patho- 
genic and  produce  mild  or  serious  illness. 

The  published  cases  of  bacteriuria  are  not  very  numerous,  and  their 
details  will  not  as  yet  admit  of  succinct  didactic  description,  but 
they  are  suggestive.  The  details  of  eight  cases  reported  by  Krogius 
are  interesting.  Of  these  cases,  three  were  in  men  and  five  in  women  of 
advanced  age.  The  men  had  presumably  been  cured  of  urethral  and 
bladder  inflammation.  The  histories  of  the  women  showed  that  some 
had  had  antecedent  pelvic  aifections  and  had  been  operated  upon,  others 
had  borne  children,  while  others  still  had  been  catheterized.  In  some 
of  these  cases,  without  known  exciting  cause,  the  urine  became  fetid, 
more  or  less  opaque,  and  loaded  with  bacteria.  In  only  one  of  these 
cases  was  increased  micturition  observed  ;  but  in  some  there  were  symp- 
toms of  ill-health,  such  as  chills  and  fever  and  emaciation.  These  cases 
were  not  instances  of  urinary  infection  nor  of  cystitis.  Other  cases 
have  been  reported  without  inflammatory  change  in  the  large  intestine  and 
rectum,  which  were  accompanied  by  bacteriuria,  and  the  opinion  has  been 
advanced  that  the  infection  occurred  from  these  parts  and  spread 
through  the  bladder-walls  without  producing  cystitis. 

Bacterial  urine  has  a  cloudy,  opaque  appearance,  and  when  shaken 
an  undulatory  or  eddying  motion  may  be  seen,  as  if  it  contained  an 
impalpable  powder.  Its  odor  is  like  that  of  stale  or  decayed  fish,  and 
is  very  penetrating  and  nauseating. 

The  chief  microbe  found  in  bacteriuria  is  the  Bacterium  coli  com- 
mune ;  but  certain  streptococci,  the  Proteus  vulgaris,  and  the  Bacillus 
subtilis  may  also  be  found. 

Treatment. — Irrigations  and  instillations  in  the  deep  urethra  and 
bladder  may  be  beneficial  in  some  cases.  All  intestinal  and  pelvic 
disorders  should  be  actively  treated  according  to  indications. 

INCONTINENCE  OF  URINE  (ENURESIS). 

By  incontinence  of  urine  is  meant  the  inability  of  the  bladder  to 
retain  its  contents  either  wholly  or  in  part.  It  is,  strictly  speaking, 
merely  a  symptom   of  many  morbid  conditions,  and  is  not  a  disease  in 


INCONTINENCE  IN  CHILDREN.  431 

itself ;  thus  we  have  incontinence  due  to  diseases  of  the  nervous  system 
without  lesions  of  the  urinary  tract,  and  again  incontinence  due  to 
pathological  conditions  of  the  urinary  organs,  such  as  urethrocystitis, 
prostatitis,  hypertrophy,  tuberculosis,  malignant  disease  of  the  prostate, 
vesical  calculus,  hypertrophy  of  the  bladder-walls,  with  great  diminu- 
tion of  its  capacity,  and  lesions  of  the  vesical  neck. 

Treatment. — The  cause  of  the  incontinence  must  be  sought  for  and 
removed.  This  knowledge  may  be  obtained  by  a  urinary  analysis  and 
an  examination  of  the  nervous  system,  followed  by  a  local  examination 
of  the  bladder,  vesicles,  prostate,  and  urethra.  All  diseased  conditions 
should  be  treated,  as  already  described  in  this  work  under  the  appro- 
priate headings. 

Epidural  Injections. — A  novel  and  radical  treatment  of  enuresis 
has  been  proposed  by  Cathelin.  The  injections  are  made  into  the  sacral 
canal  between  the  periosteum  of  the  vertebra?  and  the  dura  mater.  The 
canal  is  reached  through  its  opening  in  the  sacrum.  The  patient  is 
placed  in  the  Sims  position,  the  area  sterilized,  and  the  small  osseous 
tubercles  just  below  and  to  either  side  of  the  last  palpable  spinous  process 
are  made  out.  The  needle  of  an  aspirating-syringe  is  then  thrust  through 
the  skin  drawn  tightly  between  these  two  tubercles,  the  needle  being  held 
at  an  angle  of  40  degrees  to  the  sacral  curve  until  it  passes  through  the 
membrane  covering  the  opening  of  the  canal,  when  it  is  lowered  to  20 
degrees  and  pushed  on  into  the  canal.  Five  c.c.  of  sterile  salt  solution 
are  usually  injected  at  first,  and  later  10  or  even  15.  These  injections 
are  made  at  intervals  of  about  one  week,  and  favorable  results  are  said 
to  follow  immediately.  The  injections  seem  to  be  in  nowise  harmful  to 
the  patient,  and  are  no  more  painful  than  any  hypodermic  injection. 
The  immediate  effects  are  rarely  even  disagreeable.  The  rationale  of  the 
treatment  is  not  fully  understood,  though  it  is  conjectured  that  the  result 
obtained  may  be  explained  on  the  basis  of  a  vertebral  inhibition  due  to 
traumatism  exerted  upon  the  nerve-roots  and  conveyed  to  the  medullary 
centres. 

We  can  await  with  equanimity^ the  verdict  of  time  on  this  procedure. 

Incontinence  in  Children. 

This  form  is,  as  a  rule,  nocturnal,  although  cases  are  met  with  in 
which  it  occurs  during  both  day  and  night.  It  may  continue  from  in- 
fancy, the  child  never  seeming  to  be  able  to  exercise  control  over  the 
bladder  musculature  ;  or  it  may  not  begin  until  the  third  or  fourth 
year,  or  even  later.  As  a  rule,  the  affection  disappears  as  the  child 
nears  puberty. 

Treatment. — In  treating  these  young  patients,  the  surgeon  should 
always  ascertain  the  cause  of  the  trouble,  and  if  possible  remove  it,  and 


432  AFFECTIONS  OF  THE  GENITO-UBINABY  SYSTEM. 

to  this  end  a  thorough  examination  of  the  nervous  system  should  be 
made  ;  then  a  quantitative  and  qualitative  urinary  analysis  will  be 
necessary,  as  this  will  point  to  any  kidney,  vesical,  or  deep  urethral 
trouble.  If  these  examinations  prove  negative,  we  should  ascertain 
whether  the  child  is  infested  with  worms  or  a  lesion  of  the  rectum  or 
anus  is  present.  A  phimotic  condition  of  the  prepuce  will  sometimes 
cause  incontinence,  as  will  also  stone  in  the  bladder  or  congenital  ure- 
thral narrowing.  Errors  in  the  management  of  the  child,  such  as  not 
urging  him  to  urinate  just  before  going  to  sleep,  or  awakening  him  at 
night  and  early  in  the  morning  for  the  same  purpose,  must  be  corrected 
and  regulated.  He  must  not  be  allowed  to  take  much  fluid  during 
the  evening  and  before  going  to  sleep.  Among  the  many  drugs  recom- 
mended for  the  relief  of  incontinence  in  children,  belladonna  and  qui- 
nine are,  as  a  rule,  the  most  useful,  beginning  with  small  doses  accord- 
ing to  the  age  of  the  patient  and  increasing  up  to  the  full  amount. 
The  employment  of  local  treatment  by  means  of  appliances  about  the 
external  genitals  is  to  be  most  emphatically  condemned,  since  it  is  lia- 
ble, by  directing  the  child's  attention  to  these  parts,  to  be  followed  by 
masturbation. 


CHAPTER   XXII. 

PREPARATION  OF  THE  PATIENT  FOR  OPERATIONS  AND  OF 

INSTRUMENTS. 

PREPARATION  OF  THE  PATIENT. 

For  all  operations  of  magnitude  on  the  genito-urinary  tract,  the 
proper  preparation  of  the  patient,  both  locally  and  constitutionally,  is 
a  most  important  factor  in  the  ultimate  outcome  of  the  case,  and 
should,  therefore,  be  attended  to  most  minutely. 

The  urine  must  be  thoroughly  analyzed,  both  chemically  and  micro- 
scopically, and  quantitatively  determined,  and  suitable  measures  insti- 
tuted to  ensure  its  amount  normal,  to  correct  its  reaction,  and  to  make 
it  as  bland  and  non-irritating  as  possible. 

The  heart  and  lungs  are  next  examined,  and  if  abnormal  conditions 
exist  they  should  be  dealt  with  according  to  indications. 

Tonics  in  general,  but  especially  full  doses  of  strychnine  and  quinine, 
are  of  great  benefit  both  before  and  after  operations  on  the  genito- 
urinary tract. 

Bland  and  non-irritating  bladder  and  urethral  irrigations  should  be 
given  when  indicated  for  several  days  prior  to  operation,  and  the 
patient  made  to  urinate  just  before  taking  the  anaesthetic.  The  patient 
should  be  kept  very  quiet  for  a  day  or  so  before  the  operation.  On 
the  night  before,  a  cathartic  pill  should  be  given,  and  a  few  hours 
before  the  operation  he  should  receive  a  warm  saline  enema. 

On  the  preceding  night  the  operative  field  is  shaved,  scrubbed 
with  soap  and  hot  water,  and  then  covered  with  a  1 :  2000  wet 
bichloride  and  oiled  silk  dressing,  which  is  held  in  place  by  a  suitable 
bandage. 

The  patient  being  anaesthetized,  the  operative  field  is  scrubbed  with 
tincture  of  green  soap  and  hot  water,  then  with  equal  parts  of  alcohol 
and  ether,  then  with  a  1  :  2000  bichloride  solution,  and  finally  with 
sterile  salt  solution.  The  surrounding  parts  should  be  covered  with 
towels  moistened  with  bichloride,  over  which  are  laid  dry  sterilized 
towels.  It  is  most  important  to  have  all  solutions  and  towels  that  come 
in  contact  with  the  patient  kept  warm. 

The  preputial  cavity  must  be  thoroughly  cleansed  as  described 
above,  the  penis  being  bandaged  in  a  wet  bichloride  dressing  in  all 
operations  in  which  the  urethral  route  does  not  form  a  part. 

28  433 


434  PREPARATION   OF  THE  PATIENT. 

It  is  necessary  to  emphasize  the  fact  that  in  these  patients  the 
bowels  should  be  freely  moved  every  day  following  the  operation. 

PREPARATION  OF  INSTRUMENTS. 

All  metal  instruments,  except  knives,  are  scrubbed  with  soap  and 
hot  water,  then  rinsed  in  hot  water  and  boiled  for  fifteen  minutes  in 
a  2  per  cent,  carbonate  of  sodium  solution.  Thus  prepared,  the  instru- 
ments are  laid  in  trays  of  warm  sterile  water  or  saline  solution. 

Knives  are  first  washed  in  soap  and  hot  water,  then  in  sterile  water, 
and  laid  in  absolute  alcohol,  or  1 :  20  carbolic  acid  solution,  from  which 
they  are  taken  for  use. 

Soft-rubber  catheters  should  be  boiled,  as  may  also  most  of  the  new- 
make  of  woven  and  gum  elastic  instruments,  their  interior  having  pre- 
viously been  cleansed  by  injecting  hot  soapsuds  and  then  plain  hot 
sterile  water  through  them. 

Filiform  bougies  must  not  be  boiled,  as  it  renders  them  soft  and  unfit 
for  use.  They  are  washed  in  soap  and  cold  water,  rinsed  in  sterile 
water,  and  wiped  dry  on  sterile  gauze,  in  which  they  are  laid  ready 
for  use. 

For  the  lubrication  of  instruments,  lubrichondrin,  white  vaseline, 
glycerin,  or  olive  oil  may  be  employed,  all  of  them  being  thoroughly 
sterilized  just  before  use,  and  kept  either  in  collapsable  tubes  or  tightly 
stoppered  deep  glass  jars. 


CHAPTER   XXIII. 

THE  CHANCROID,  OR  SOFT  CHANCRE. 

Nature  of  the  Chancroid. — Such  is  the  general  acceptance  of  the 
term  "  chancroid "  or  "soft  chancre"  in  this  country,  in  contradis- 
tinction to  the  hard  chancre,  or  initial  lesion  of  syphilis,  that  it  is 
well  to  retain  it. 

The  chancroid  is  an  infectious  ulcer  of  the  genitals,  inflammatory  in 
its  nature  and  very  destructive  in  its  course.  It  never,  under  any  cir- 
cumstances, leads  to  syphilis  nor  any  form  of  systemic  infection.  Its 
action  is  purely  local  to  the  parts  upon  which  it  develops  and  to  the 
lymphatic  vessels  and  ganglia  in  immediate  anatomical  association  with 
those  parts. 

The  vehicle  of  infection  of  the  chancroid  in  clinical  practice  is  the 
secretion  of  a  chancroid,  of  chancroidal  lymphangitis,  of  a  chancroidal 
bubo,  or  of  a  serpiginous  chancroidal  ulcer.  Besides  these  secretions, 
inflammatory  pus  and  pus  resulting  from  severe  irritation  of  syphilitic 
lesions  are  also  capable  of  producing  chancroidal  ulcers  de  novo  in  both 
male  and  female,  the  person  from  whom  the  infection  is  derived  being 
perhaps  free  from  active  chancroids  at  the  time. 

A  marked  peculiarity  of  the  chancroid  is  its  amenability  to  repro- 
duction upon  its  bearer  by  auto-inoculation.  Its  secretion  may  be  trans- 
mitted to  the  lower  animals  by  inoculation. 

Modes  of  Infection. — Chancroidal  contagion  takes  place  most  com- 
monly, in  the  lower  classes,  by  actual  contact,  the  pus  being  transferred 
from  one  person  to  another  in  the  act  of  coitus  or  in  some  other  intimate 
mode  of  direct  transfer.  This  mode  is  called  "direct  infection." 
While  in  syphilis  mediate  infection  is  rather  common,  in  chancroid  it  is 
quite  rare.  Instances  in  which  patients  have  transferred  chancroids  by 
means  of  their  fingers  or  nails  to  other  portions  of  the  body  through 
scratching  or  other  modes  of  transference  occur,  though  very  rarely. 

It  is  probable  that  chancroidal  inoculation  in  sexual  intercourse  in 
many  instances  takes  place  as  a  result  of  more  or  less  well-marked  ero- 
sions, abrasions,  tears,  and  rents  in  the  mucous  membrane,  and  even  on 
the  surface  of  herpetic  vesicles.  It  is  also  fair  to  assume  that  the  balano- 
preputial  mucous  membrane,  with  its  delicate  epithelium  and  its  rich 
and  very  copious  capillary  system,  especially  as  it  is  subject  to  the 
heat,  moisture,  and   maceration  affecting  the  structure  of  the  parts,  may 

435 


436  THE  CHANCROID. 

be  eroded  by  the  irritating  pus  and  become  the  seat  of  chancroids. 
This  secretion  may  lodge  in  the  ducts  of  the  sebaceous  follicles  of  the 
integument  of  the  penis,  and  there  produce  ulceration. 

Chancroid  being  classed  as  a  venereal  disease,  the  physician  instinc- 
tively concludes  that  a  given  ulcer  that  is  presented  to  him  must  of 
necessity  have  originated  in  sexual  contact.  In  many  cases  this  supposi- 
tion is  not  correct,  for  chancroids  may,  as  we  have  seen,  originate  in  some 
subjects  de  novo.  In  other  words,  it  is  not  very  uncommon  to  see  chan- 
croids in  men  who  have  had  no  sexual  exposure  whatever,  such  lesions 
being  perhaps  due  to  inherent  peculiarities  of  their  tissues,  to  some 
diathetic  condition  or  debility,  or  to  contamination  with  particles  of  dirt 
that  have  lodged  upon  their  genital  organ.  This  mode  of  origin  of  the 
chancroid  has  been  conclusively  demonstrated  to  me  by  very  many  cases 
in  which  herpetic  lesions  became  transformed  into  actively  destructive 
chancroids.  Such  cases  are  far  from  rare,  and  if  the  practitioner  will 
carefully  interrogate  the  patients  that  come  to  him  suffering  from  chan- 
croids, he  will  in  many  instances  find  that  there  has  been  no  exposure 
within  the  time  required  for  the  development  of  these  lesions,  and  he 
will  convince  himself  beyond  all  doubt  that  the  ulcerative  lesions  are 
due  to  some  unknown  source  of  contamination  of  herpetic  vesicles,  of 
chafes,  abrasions,  or  fissures.  Simple  inflammatory  lesions  of  the 
genitals,  therefore,  become  converted  into  typical  chancroids — or,  as  we 
may  say,  wound-infections  or  septic  ulcers — undoubtedly  as  the  result 
of  contamination  with  pyogenic  microbes.  Pus  taken  from  these  chan- 
croids in  syphilitic  subjects  will,  as  a  rule,  be  seen  to  possess  great 
potentiality  in  the  extent  and  persistence  of  the  ulcer  and  in  the  power 
that  it  possesses  of  producing  by  inoculation  similar  lesions  for  many 
generations. 

In  some  of  these  cases  of  chancroid  that  develop  de  novo  in  syphilitic 
subjects  contamination  of  the  inguinal  ganglia  takes  place  by  direct 
lymphatic  absorption.  As  a  result  we  have  two  forms  of  bubo — the 
irritative,  which  may  be  aborted  ;  and  the  inflammatory,  which  leads  to 
abscess. 

It  is  very  probable  that  in  the  tissues  of  syphilitic  subjects  the 
pyogenic  microbes  find  a  most  favorable  nidus.  The  inflammatory 
process  to  which  they  give  rise  is  often  very  active,  and  the  resulting 
pus,  rich  in  microbes  and  their  poisons  or  tissue-products,  is  much  more 
virulent  and  destructive  than  that  of  their  congeners,  which  are  caused 
by  the  various  forms  of  simple  pus. 

Chancroidal  pus  and  pyogenic  microbes  may  attack  the  hard  chancre 
and  cause  it  to  resemble  chancroid.  The  resulting  lesion  is  called  the 
mixed  chancre. 

Bacteriology  of  the  Chancroid. — Within  the  past  ten  years  several 


APPEARANCES  OF  THE  CHANCROID.  437 

observers  have  endeavored  to  prove  that  in  chancroidal  pus  and  in 
mucous  membranes  the  seat  of  chancroidal  ulcerations  they  have  found 
a  specific  micro-organism,  which  is  known  to-day  as  the  streptobacillus 
of  Ducrey ;  but  their  descriptions  and  observations  are  faulty  and  lack- 
ing in  many  essential  particulars,  and  they  fail  to  carry  conviction. 

These  observers,  who  devote  so  much  time  to  the  microscopic  study 
of  the  soft  chancre,  are  silent  about  its  multifarious  origin.  Chancroid 
bears  the  same  relation  to  mucous  membranes  that  impetigo  and  ecthyma 
do  to  the  general  integument.  Knowing  as  we  do  that  chancroid  may 
arise  from  so  many  different  pyogenic  processes,  that  it  can  be  readily 
produced  at  pleasure  by  any  one  who  will  take  the  trouble  to  make  the 
necessary  experiments  and  inoculations,  that  it  frequently  arises  de  novo 
when  the  genital  parts  are  subjected  to  irritation,  dirt,  and  unclean- 
liness — it  is  utterly  absurd  to  call  it  a  specific  process  and  due  to  a 
special  specific  cause.  This  streptobacillus  is  a  pus-producing  agent, 
it  may  be  that  it  follows  in  the  wake  of  the  well-known  pyogenic 
microbes,  after  the  manner  of  mixed  infections.  It  must  be  distinctly 
borne  in  mind  that  when  chancroidal  pus  is  examined  with  high  powers 
and  oil-immersion  by  means  of  the  microscope,  it  is  invariably  found  to 
contain  staphylococci,  streptococci,  indifferent  cocci,  and  bacilli.  The 
science  of  bacteriology  is  not  yet  far  enough  advanced,  nor  are  its  results 
sufficiently  accurate  and  extensive  from  a  diagnostic  point  of  view,  to 
warrant  the  statements  which  have  been  made  concerning  this  strepto- 
bacillus. 

Description  of  the  Ducrey-Unna  Streptobacillus. — The 
streptobacillus  of  soft  chancre  was  found  in  pus  first  by  Ducrey,  and 
later  in  the  tissues  by  Unna.  It  is  a  rod-like  bacillus  with  rounded  ends. 
The  dimensions  vary  from  1.5  to  2  /j.  in  length  and  from  0.3  to  1  /x  in 
breadth.  This  micro-organism  is  found  singly,  but  it  shows  a  tendency 
to  form  chains  and  to  become  agglomerated  in  masses.  In  the  pus  it 
occurs  singly,  but  more  frequently  in  chains.  In  the  tissues  it  is  found 
almost  entirely  in  chain-form.  It  has  been  found  in  all  soft  chancres 
examined  by  Unna,  and  also  in  the  pus  of  chancroidal  buboes.  It  stains 
with  carbol-fuchsin,  gentian-violet,  and  anilin-water  solution,  and  is 
decolorized  by  Gram's  method — a  characteristic  by  which  it  may  be  dif- 
ferentiated from  other  organisms  occurring  in  chancroidal  pus. 

Recently  the  Unna-Ducrey  bacillus  has  been  successfully  cultivated 
by  Bezancon,  Griffon,  Le  Sourd,  and  Lincoln  Davis  of  Boston.  These 
observers  obtained  pure  cultures  in  several  cases  from  chancroidal  buboes 
opened  under  aseptic  conditions,  and  from  extragenital  chancroids.  Of 
the  latter,  one  was  the  result  of  auto-inoculation  upon  the  thigh  from 
a  genital  lesion  ;  the  other  was  an  artificial  inoculation  upon  the  abdo- 
men from  a  irenital  lesion.     The  culture-medium  used  was  rabbit's  blood- 


438  THE  CHANCROID. 

agar  in  a  proportion  of  one-third  to  two-thirds  agar ;  also  uncoagulated 
rabbit's  blood-serum.  The  colonies  were  described  as  appearing  at  the 
end  of  twenty-four  hours,  on  the  solid  media,  as  bright  round  globules 
which  attained  their  complete  development  in  forty-eight  hours,  becom- 
ing then  opaque  and  grayish.  They  were  1  to  2  mm.  in  diameter,  and 
never  became  confluent.  When  stained  and  examined  they  were  found 
to  be  composed  of  bacilli  grouped  in  masses  or  arranged  in  chains  of 
three  or  four  elements.     In  morphology  these  bacilli  corresponded  to  the 

Fig.  112. 

VJSVl*i*2i&"Vtf  •  ' 
>?#§<    S  Ul*f 


Section  of  a  chancroid,  showing  the  streptobacillus  of  Ducrey-Unna  in  the  tissues.  The  chains 
are  composed  of  minute  rods  arranged  linearly,  mostly  in  two  or  three  parallel  rows,  and  they 
give  off  branches  in  their  course.  Single  rows  of  the  bacilli  are  also  found.  They  lie  between 
the  cells,  not  in  them,  and  are  situated  especially  in  the  superficial  layers  of  the  tissues. 
Deeper  dowTn  in  the  section  they  are  not  seen.1 

descriptions  of  the  organisms  of  Ducrey  and  Unna.  In  the  water  of 
condensation  the  bacilli  were  found  arranged  in  long,  sinuous  chains  in 
which  the  individual  elements  were  smaller  than  in  the  surface  colonies. 

The  growth  of  the  bacilli  was  equally  good  in  rabbit's  blood-serum 
uncoagulated.  Their  vitality  in  this  medium,  however,  was  short,  while 
on  blood-agar  it  exceeded  three  weeks.  All  attempts  at  cultivation  on 
ordinary  media  failed,  even  after  acclimation  through  a  series  of  tubes  of 
blood-agar.  Typical  chancroidal  lesions  were  reproduced  on  three  occa- 
sions in  man  by  inoculation  from  pure  cultures.  From  these  chancroids  of 
inoculation  the  organism  was  recovered  in  pure  culture.  Animal  inocu- 
lations were  in  all  cases  negative.     Monkeys  were  not  used. 

This  work  of  Bezancon  and  others  has  since  been  confirmed  by  Simon, 
and  very  recently  by  Tomaszewski  in  a  small  number  of  cases. 

Nicolle  was  the  first  to  produce  the  disease  in  animals  by  inoculation 

of  chancroidal  pus.     He  succeeded  in  doing  this  in  1900  with  certain 

species  of  monkeys,  notably  the  Semnopithecus. 

1  This  drawing  was  kindly  made  for  me  by  Dr.  George  T.  Elliot  from  a  section  made 
and  stained  by  Unna. 


APPEARANCES  OF  THE  CHANCROID.  439 

Recently  Holub,  a  Russian  observer,  has  reported  the  growth  of  the 
streptobacillus  of  Ducrey  in  the  internal  organs  of  various  insects  inocu- 
lated with  chancroidal  pus.  More  recently,  1903,  Lincoln  Davis  success- 
fully inoculated  cultures  of  the  Ducrey  bacillus  upon  a  monkey  of  the 
genus  Maccasus  Nemestrinus. 

Appearances  of  the  Chancroid. — Chancroidal  ulcers  have  no 
period  of  incubation,  since  the  destructive  action  of  the  pus  or  of  the 
pyogenic  microbes  begins  at  once,  and  the  resulting  lesion  is  apparent 
as  soon  as  the  morbid  action  penetrates  beneath  the  epithelium.  Thus, 
when  this  layer  is  thick  the  appearance  of  the  chancroid  may  be  delayed, 
and  very  often  some  time  elapses  during  which  the  pus  is  entering  a 
follicle.  Constitutional  conditions  in  many  cases  influence  the  rapidity 
of  development.  Chancroids  on  mucous  surfaces  develop  much  more 
quickly  than  upon  the  integument.  Abrasions,  excoriations,  and  fissures 
in  the  mucous  membrane  afford  favorable  doors  of  entry,  and  upon  them 
chancroids  develop  with  great  promptness.  As  a  rule,  inflammatory 
action  is  very  apparent  within  twenty-four  hours  after  the  implantation 
of  the  pus  on  mucous  membranes,  and  within  forty-eight  hours  in  general 
the  pustular  nature  of  the  lesion  can  be  readily  made  out.  In  other 
cases  the  progress  may  be  slower,  and  three  or  four  days  may  elapse 
before  the  chancroid  pustule  is  fully  formed. 

Upon  mucous  membranes  the  first  sign  of  a  chancroid  is  a  minute 
yellow  spot  surrounded  by  a  halo  of  intense  redness,  which  shades  off 
into  the  surrounding  pink  color.  If  not  ruptured,  the  yellow  central 
spot  grows  larger  and  higher,  and  very  soon  a  typical  conical  shaped 
pustule  is  formed.  Upon  the  integument  the  same  yellow  spot  and  red 
halo  are  present,  and  the  pustular  condition  may  be  present  or  may  be 
replaced  by  an  ulceration. 

In  most  cases  on  mucous  membranes  chancroids  very  early  lose  their 
epithelial  dome,  which  constitutes  the  pustule,  and  the  typical  ulcer  is 
then  seen. 

The  outline  of  a  chancroid  is  usually  either  round  or  oval,  according 
to  the  conformation  of  the  parts  upon  which  it  is  seated  ;  but  when  de- 
veloped upon  a  fissure  or  abrasion  it  may  be  linear  or  irregular.  Irreg- 
ularity of  outline  also  results  from  the  coalescence  of  a  number  of 
chancroids.  On  the  prepuce  and  in  the  sulcus  they  are  circular  ;  about 
the  frsenum  they  frequently  are  oval ;  when  developed  partly  on  the 
glans  and  partly  on  the  prepuce  they  are  irregular,  for  the  reason  that 
the  ulcerative  process  is  more  active  on  the  former  than  on  the  latter. 
Chancroids  at  the  orifice  of  the  prepuce  and  at  the  anus  have  a  tendency 
to  follow  the  radiating  fissures  peculiar  to  these  parts.  A  comprehen- 
sive idea  of  the  clinical  feature  of  chancroids  may  be  gained  bv  a 
survey  of   Plate  XXYI.     Fig.   1    shows   incipient   chancroids   on   the 


440  THE  CHANCROID. 

inner  lamella  of  the  prepuce,  while  in  Fig.  2  a  w ell-developed  chancroid 
of  the  integument  is  portrayed. 

Whatever  the  shape  of  the  chancroid,  the  edges  are  sharply  cut  and 
abrupt,  as  if  punched  out.  The  whole  thickness  of  the  epithelium  is 
destroyed,  and  it  can  be  seen  that  though  cleanly  cut,  as  is  the  result- 
ing lesion,  the  edges  of  it  are  undermined  in  some  cases  to  such  an 
extent  that  the  tip  of  a  probe  can  be  carried  circumferentially  around 
the  ulcer  and  under  it.  This  feature  of  undermined  edge  is  due  to  the 
fact  that  the  soft  subepithelial  tissues  are  less  resistant  than  the  more 
horny  epithelium.  In  addition  to  the  undermined  condition,  the  edges 
are  frequently  minutely  uneven  or  jagged,  as  best  seen  by  a  magnify- 
ing-glass,  showing  that  the  destructive  action  takes  place  by  minute 
radiating  processes.  Around  the  edge  of  the  chancroid  is  an  areola  of 
redness  which  varies  in  depth  and  width  according  to  the  stage  of  the 
inflammation.  This  red  halo  extends  pari  passu  with  the  ulcer.  The 
floor  of  the  latter  is  peculiarly  uneven  and  worm-eaten  in  appearance, 
and  in  its  early  stage  covered  with  a  light  yellowish  pellicle  composed 
of  disorganized  tissues  and  pus.  AVith  the  growth  of  the  ulcer  this 
film  becomes  thicker  and  forms  a  bright  or  golden-yellow  pseudomem- 
branous layer,  which  is  shown  with  admirable  fidelity  in  Figs.  1,  2,  3, 
and  4  of  Plate  XXVI.  This  membranous  pellicle  covering  the  chancroid 
is  thrown  into  little  uneven  mammillations,  which  correspond  to  the 
minute  rugosities  which  cover  the  surface  of  the  ulcer. 

The  secretion  of  chancroids  is  in  the  active  stage  quite  abundant, 
and,  while  purulent,  the  pus  differs  from  that  of  gonorrhoea.  It  is 
thinner  in  quality  and  usually  of  a  brownish  or  rusty-brown  tint,  due 
to  the  admixture  of  small  quantities  of  blood.  This  chancroidal  pus 
under  the  microscope  is  found  to  consist  of  pus-globules,  red  corpuscles, 
and  the  detritus  of  tissues  and  micro-organisms. 

The  underlying  bed,  as  it  may  be  called,  of  chancroids  should  always 
be  attentively  studied.  It  usually  consists  of  ordinary  inflammatory 
oedema,  and  is  felt  between  the  thumb  and  finger  as  a  mass  firm  in  con- 
sistence midway  between  ordinary  cedema  and  a  furuncle.  It  yields 
to  firm  pressure,  though  not  doughy,  but  has  not  the  dense  consist- 
ency of  the  true  hard  chancre.  This  cedematous  infiltration  of  the 
chancroid  is  not  very  sharply  limited,  but  becomes  gradually  less  in  the 
surrounding  tissue. 

In  the  typical  hard  chancre  the  induration,  on  the  other  hand,  is 
condensed  and  sharply  circumscribed.  This  symptom,  to  a  certain  de- 
gree important  in  the  diagnosis  of  the  chancroid,  is  often  much  ob- 
scured by  injudicious  cauterization,  particularly  when  the  solid  stick  of 
nitrate  of  silver  is  vigorously  used,  and  also  when  chromic  acid,  pure 
sulphuric   acid,  and  indeed   any  very  caustic  application,  is  made.     A 


PLATE  XXVI. 


CHANCROIDS. 


SEAT  OF  THE  CHANCROID.  441 

similar  misleading  hardness  is  very  often  felt  after  active  cauteriza- 
tion of  herpetic  vesicles,  abrasions,  fissures,  and  vegetations. 

The  duration  of  the  period  of  activity  of  chancroid  is  so  variable 
that  it  is  really  indefinite.  It  is  influenced  laro-elv  bv  the  intelligence 
and  efficiency  of  the  treatment,  the  care  and  attention  of  the  patient, 
and  by  his  general  condition  and  modes  of  life.  Alcoholic  indulgence 
is  a  prolific  cause  of  chronicity  and  activity  of  chancroidal  ulceration, 
and  plethora  tends  to  increase  it.  A  very  active  life,  much  walking, 
and  physical  exercise  likewise  tend  to  perpetuate  the  existence  of  these 
sores. 

On  the  integument  the  ulceration  is  slow,  and  there  is  not  the 
marked  tendency  to  extension  that  there  is  on  mucous  membranes.  In 
some  instances  the  ulceration  extends  quite  superficially  over  consider- 
able surface.  Then,  again,  the  ulceration  grows  in  extent  by  the  fusion 
of  a  number  of  chancroids,  as  depicted  in  Fig.  6  of  Plate  XXVI.,  in 
which  it  will  be  seen  that  a  large  portion  of  the  surface  of  the  integu- 
ment of  the  penis  has  been  invaded.  In  Fig.  4  an  active  chancroid  is 
seen  complicated  by  the  development  of  another  chancroid  in  the 
course  of  the  lymphatics,  called  bubonulus — a  feature  first  described  by 
Nisbet. 

The  stage  of  repair  of  chancroids  is  indicated  by  a  number  of  changes 
in  all  of  the  features  of  the  ulcer.  Perhaps  the  most  noticeable  one  is 
a  diminution  of  the  inflammatory  areola  and  a  subsidence  of  the  under- 
lying (edematous  infiltration.  Then  the  grayish-yellow  well-marked 
pseudomembranous  layer  begins  to  disappear,  and  as  it  does  healthy 
pink  granulations  spring  up  over  more  or  less  of  the  surface  and  the 
unhealthy  pus  becomes  gradually  laudable.  The  undermined  edges 
lose  their  deep  redness  and  gradually  disappear,  and  the  ulcer  becomes 
saucer-shaped.  Coincidently  with  this,  healthy  granulations  develop 
over  the  whole  surface  and  push  upward,  gradually  becoming  even  with 
the  parts  around. 

A  remarkable  feature  of  the  chancroidal  ulcer  when  not  kept  scru- 
pulously clean  is  its  tendency,  even  in  the  reparative  stage,  to  retrogress 
and  assume  all  of  the  attributes  of  activity.  In  such  cases,  however, 
there  is  usually  some  well-defined  cause  for  the  exacerbation,  such  as 
carelessness,  and  particularly  uncleanliness,  sexual  intercourse,  or  al- 
coholic excesses. 

Seat  of  the  Chancroid. — In  the  male  the  chancroid  is  most  com- 
monly found  in  the  sulcus  behind  the  glans  ;  on  the  inner  surface  of  the 
prepuce  ;  on  and  near  the  fourchette,  particularly  on  the  fossa?  on  each 
side  of  it ;  on  the  lips  of  the  meatus  and  within  the  urethra  ;  upon  the 
sheath  of  the  penis  ;  on  the  glans  ;  and,  usually  by  auto-inoculation,  on 
the  scrotum  and   thighs,  pubes  and  anus.     They  occur  on  the  finger  by 


442  THE  CH AS  CROW. 

infection  from  genital  sores,  and  upon  the  face  by  means  of  the  fingers, 
and  within  the  anus  from  pederasty.  In  women  they  are  found  at  the 
introitus  vaginae ;  on  the  fourchette  and  vestibule  and  on  the  clitoris  ; 
on  the  labia  minora  ;  within  the  vagina  (rather  rarely) ;  on  the  os  uteri ; 
on  the  labia  majora,  and  by  auto-inoculation  on  the  integument  of  the 
latter  bodies  ;  upon  the  perineum,  inner  surface  of  the  thighs  ;  on  the 
hvpogastrium,  and  around  the  margin  of,  and  within,  the  anus.  (See 
Fig.  113.) 

Upon  the  external  and  integumental  surface  of  the  labia  majora 
chancroids  often  assume  the  appearance  of  pustules  or  abscesses  in  con- 
sequence of  the  pus  having  inoculated  one  or  more  of  the  follicles  (fol- 
licular chancroids) ;  and  there  is  frequently  more  or  less  oedema  of  the 
subcutaneous  cellular  tissue,  as  evinced  by  the  swelling  and  hardness  of 
the  labia.  "When  the  pustule  breaks  the  underlying  ulcer,  if  exposed  to 
the  air,  becomes  covered  with  a  scab  and  resembles  ecthyma. 

Chancroids  are  also  common  on  other  portions  of  the  vulva  and  on 
the  internal  surface  of  the  labia  majora,  where  they  occasion  pain  and 
difficulty  in  walking.  Vulvar  ulcers  become  much  inflamed  from  the 
irritation  of  the  urine  and  vaginal  discharges,  which  likewise  renders 
them  difficult  to  cure. 

Varying  Features  of  Chancroidal  Ulcers. — The  most  simple  form 
of  chancroid  is  very  shallow  (see  Plate  XXVI.,  Fig.  1) ;  the  under- 
mining' of  the  edges  is  very  slight,  and  the  worm-eaten  unevenness  of 
the  base  very  delicate.  This  condition  may  really  be  but  the  early  stage 
of  the  ulcer,  and  appropriate  treatment  very  soon  brings  about  the  repar- 
ative stage. 

Upon  surfaces  where  mucous  membranes  and  integument  meet,  and 
upon  the  mucous  membrane  lining  the  labia  majora,  and  on  the  skin  in 
the  region  of  the  genitals,  rounded  conical  elevations  surmounted  with  a 
minute  pustule  are  sometimes  seen.  The  pustule  increases  in  size,  and 
forms  an  ulcer  which  presents  a  crater-like  appearance,  as  sometimes 
seen  in  acne  indurata.  This  lesion  is  called  the  follicular  or  acneform 
chancroid,  and  results  from  the  destructive  action  of  the  pus,  beginning 
in  the  hair-  or  sebaceous  follicles  and  accompanied  by  much  inflam- 
matorv  swelling.  It  is  shown  in  Fig.  113  on  the  upper  part  of  the  left 
labium  majus.  (Comparison  of  the  outlines  furnished  by  this  figure 
with  the  colored  figures  will  give  a  clear  idea  of  chancroids  in  women.) 

What  is  termed  the  echthymatous  chancroid  is  always  met  with  upon 
the  integument,  particularly  upon  the  penis  and  those  parts  of  the  geni- 
tals of  both  sexes  which  are  not  macerated  with  perspiration  or  which 
are  not  in  coaptation.  This  variety  of  chancroid  resembles  in  many 
of  its  features  chancroidal  ulcers  produced  by  inoculation.  It  begins  as 
a  small  red  spot,  commonly  around  a  hair-follicle,  which  increases  rather 


VARYING   FEATURES  OF  CHANCROIDAL    ULCERS. 


443 


slowly,  with  a  small,  more  or  less  perfectly  formed,  pustule  in  its 
centre.  As  the  redness  extends  the  pustule  flattens  to  a  blackish-green 
crust,  and  thus  may  attain  an  area  of  nearly  half  an  inch  before  its 
nature  is  suspected  by  the  patient.  Removal  of  the  crust  reveals  a 
typical  chancroidal  ulcer,  with  the  exception  that  the  sharply  punched-out 
and  undermined  edges  are  thicker,  as  they  are  composed  of  epidermis  ; 


Fig.  113. 


,• 


r 


Chancroids  of  the  labia  minora,  of  the  contiguous  integument,  and  of  the  margin  of  the  anus. 

the  floor  is  deeper,  corresponding  to  the  thickness  of  the  skin  ;  and  the 
base  is  more  markedly  uneven  and  worm-eaten.  The  ulcer  is  usually 
slow  in  its  course,  and  secretes  a  moderate  amount  of  pus,  which  con- 
stantly dries  into  a  crust.  Upon  the  integument  of  the  penis  or  on 
the  outer  surface  of  the  labia  majora,  where  it  frequently  occurs,  this 
chancroid  is  sometimes  accompanied  with  lymphangitis  and  adenitis. 
It  is  well  shown  after  the  removal  of  crusts  in  Fiff.  113. 


444 


THE  CHANCROID. 


In  some  cases  of  chancroids,  particularly  when  they  are  seated  upon 
the  prepuce  near  the  sulcus  glandis  and  upon  the  labia  minora,  or  on  any 
part,  in  short,  in  which,  owing  to  its  conformation,  irritation  is  apt  to 
be  severe,  the  bed,  as  we  may  call  the  underlying  tissues,  is  sometimes 
the  seat  of  more  than  usual  oedema  and  cell-infiltration.  The  result 
is,  that  the  chancroid  is  elevated  above  the  surrounding  plane,  and  it 
is  then  called  the  ulcus  elevatum.  In  like  manner,  there  is  a  syphilitic 
elevated  ulcer.  The  salience  of  the  ulcus  elevatum  is  by  some  authors 
incorrectly  said  to  be  due  to  exuberant  granulations,  whereas  inspection 
will  show  the  typical  chancroidal  surface,  with  usually  less  under- 
mining  of  the    edges   of  the  ulcer.     A  very  good   idea  of  the  ulcus 

Fig.  114. 


Serpiginous  chancroid  of  gToin  and  gluteal  region. 


elevatum  may  be  obtained  from  inspection  of  Fig.  3,  Plate  XXVI. 
(lower  and  right-hand  lesion),  and  the  larger  oval  lesion  on  the  right 
labium  minus  in  Fig.  113. 

These  ulcers,  showing  a  tendency  to  extend  rather  superficially  over 
more  or  less  surface,  are  called  serpiginous  chancroids.  The  term  should 
be  applied  to  cases  which  show  progressive  extension,  and  in  which  the 
lesion  creeps  over  much  surface.    Such  cases  perhaps  deserve  this  designa- 


VARIETIES  OF  CHANCROIDS.  445 

tion.  In  America  we,  for  the  most  part,  apply  the  term  "serpiginous 
chancroid  "  to  a  chronic,  more  or  less  deeply  destructive,  ulcer  which 
usually  has  its  beginning  in  a  chancroidal  bubo.  These  ulcers,  happily 
rare,  have  a  deep,  irregular,  fungating  surface  covered  with  a  rather 
thick,  uneven,  variegated,  brownish-red  and  grayish-green  slough  or 
membrane  and  a  sanious  pus,  and  having  thick,  bluish-red,  under- 
mined, and  often  everted  edges  extend  irregularly  over  the  abdomen 
and  thighs.  These  destructive  ulcers  are  nowadays  very  rarely  seen. 
Owing  to  our  more  efficient  treatment  and  to  the  thoroughness  of  anti- 
sepsis it  is  very  probable  that  in  the  future  serpiginous  chancroid  will 
become  a  great  rarity. 

What  is  termed  phagedenic  chancroid  is  an  example  of  the  most 
serious  complication  of  the  local  infectious  ulcer.  Phagedena  is  a  rather 
infrequent  complication  of  both  chancroid  and  hard  chancre,  and,  in  my 
experience,  occurs  more  frequently  in  the  course  of  an  initial  lesion  than 
in  that  of  the  chancroid.  For  its  production  no  special  virus  is  required. 
It  originates  in  local  causes,  such  as  neglect  of  treatment  and  improper 
treatment  of  chancroids  (intemperate  cauterization,  or  where  they  are  so 
situated  that  it  is  difficult  to  thoroughly  irrigate  them,  as  in  chancroidal 
phimosis. 

The  course  of  chancroidal  phagedena  presents  many  features  which 
point  to  a  secondary  bacterial  infection  complicating  the  chancroidal 
ulceration. 

Varieties. — Chancroids  of  the  Meatus. — These  chancroids  are 
not  very  common,  and  when  present  involve  one  or  both  sides  of  the 
orifice.  They  may  extend  downward  and  involve  the  whole  fossa 
navicularis. 

Chancrotds  of  the  VAGINA  are  very  rare,  except  in  old  syphilitic 
subjects. 

Chancroids  of  the  os  uteri  are  also  exceedingly  rare,  and  when 
present  resemble  those  seen  in  the  vulva. 

Chancroids  of  the  Anus  and  Rectum. — Chancroids  of  the  anus 
and  rectum  may  occur  in  either  sex  from  unnatural  coitus,  but  are  more 
frequent  in  women,  owing  to  the  facility  with  which  these  parts  are 
soiled  with  the  secretion  of  sores  situated  upon  the  vulva.  When  seated 
upon  the  margin  of  the  anus  they  may  readily  be  mistaken  for  fissures. 
They  are  attended  by  much  pain,  especially  during  the  passage  of  the 
faeces,  which  should  always  be  rendered  liquid  before  going  to  stool  by 
a  mucilagenous  injection. 

Chancroids  of  the  folds  of  the  anus,  even  when  cured,  may  ter- 
minate in  fissures  which  are  very  difficult  to  heal,  in  consequence  of  the 
frequent  passage  of  the  faeces  and  the  spasmodic  contraction  of  the 
sphincter  ani.     In  such  cases  the  only  certain  means  of  relief  is  to  be 


446  THE  CHANCROID, 

found  in  the  forcible  dilatation  or  rupture  of  the  sphincter  as  employed 
in  ordinary  cases  of  fissure  of  the  anus. 

Chancroids  of  the  anus  and  rectum  not  unfrequently  escape  observa- 
tion from  the  natural  reluctance  of  patients,  especially  women,  to  have 
this  part  of  the  body  examined  ;  and,  indeed,  the  surgeon  himself  is 
often  content  with  an  inspection  of  the  external  orifice  of  the  alimentary 
canal  when  a  digital  examination  would  reveal  the  presence  of  a  chan- 
croid in  the  rectum. 

Chancroids  upon  the  Integument  of  the  Penis. — The  ma- 
jority of  ulcerations  seated  upon  the  integument  of  the  penis  are 
chancres,  and  not  chancroids  ;  therefore  the  surgeon  should  be  very 
careful  in  his  diagnosis  of  lesions  in  this  region.  The  rule,  however, 
is  far  from  being  invariable,  for  I  have  met  with  many  cases  of  simple 
chancres  situated  between  the  preputial  orifice  and  the  root  of  the  penis, 
and  even  upon  the  pubes.  Chancroids  upon  the  integument  of  the  penis 
often  originate  in  a  follicle,  and  when  first  noticed  resemble  a  pustule 
or  small  abscess  (follicular  chancroids). 

Chancroids  of  the  Fr^enum. — Chancroids  of  the  fraenum  are 
especially  painful,  persistent,  and  liable  to  hemorrhage.  They  may  com- 
mence either  upon  the  free  margin  or  at  the  base  of  the  bridle.  In  the 
former  case  a  rent  or  fissure,  the  result  of  violence  during  coitus,  has 
probably  been  inoculated,  and  the  resultant  chancroid  gradually  eats 
away  the  whole  freenum  and  hollows  out  a  narrow  longitudinal  groove 
upon  the  under  surface  of  the  glans,  giving  great  annoyance,  long  per- 
sisting, and  resisting  ordinary  modes  of  treatment. 

Chancroidal  pus  under  favorable  circumstances  may  produce  char- 
acteristic lesions  upon  any  part  of  the  integument  of  the  body. 

Subpreputial  Chancroids. — Chancroids  beneath  the  prepuce  are 
usually  multiple,  cause  much  inflammatory  oedema,  and  exhibit  a 
marked  tendency  to  extensive  ulceration.  In  proportion  as  the  prepuce 
is  long  and  tight  at  its  orifice  there  is  a  tendency  to  the  production  of 
chancroidal  phimosis.  In  many  cases  chancroidal  ulcers  form  at  the 
preputial  orifices  of  the  fissures,  which  may  be  present  there  as  a  result 
of  efforts  to  retract  the  prepuce. 

Chancroidal  Lymphangitis. — Inflammation  of  the  lymphatics 
is  a  not  very  frequent  complication  of  the  chancroid.  It  is  sometimes 
seen  as  heat,  redness,  pain,  and  a  cord-like  condition  of  these  vessels  on 
either  side  of  the  penis,  corresponding  to  the  chancre.  This  condition 
may  end  in  inflammation  of  the  inguinal  ganglia  and  its  subsidence, 
or  it  may  go  on  to  the  formation  of  chancroids  along  the  sides  of  the 
penis,  and  even  at  its  root,  low  down  on  the  pubes,  as  seen  in  Fig.  4, 
Plate  XXVI. 

Chancroidal  Phimosis. — This  is  a  somewhat  rare  complication, 


INFLAMMATORY  AND   CHANCROIDAL  BUBOES. 


447 


and  is  found  mostly  in  dispensary  and  hospital  patients.  Chancroidal 
phimosis  is  usually  due  to  want  of  care  of  subpreputial  lesions,  and  fre- 
quently to  a  too  severe  cauterization  of  them.  The  prepuce  then  be- 
comes very  red,  swollen,  and  often  quite  painful,  and  from  its  orifice  a 
dark-green  or  rusty-colored  pus  escapes  in  considerable  quantity.  The 
penis  then  becomes  so  much  swollen  at 

the  glandular  portion  that  it  resembles  '..    °'_ 

a  miniature    Indian  club.     If  relief  is  '  -  ,■';  ./"*■'■  •'/  .f-,<;  ■  j 

not   given    by    operation    or  the  chan-  ,':.     {!      '      '',       '       ,<*■' 

croidal  process  stayed  by  intrapreputial  ■ 

antiseptic  injections,  the  whole  prepuce  ^ 

continues  to  become  larger  and  more 
dusky  red,  the  suffering  of  the  patient 
greater,  and  the  discharge  is  then  very 
copious  and  of  very  bad  odor.  Then, 
not  infrequently  destruction  of  the  tis- 
sues at  the  preputial  orifice  occurs,  as 
shown  in  Fig.  115.  If  relief  is  not 
afforded,  the  inner  leaf  of  the  prepuce 
or  the  glans  penis  is  more  or  less  de- 
stroyed. In  some  cases  ulceration  oc- 
curs through  the  prepuce,  and  through 
the  hole  thus  formed  the  glans  then  pro- 
trudes. In  these  severe  cases  nearly 
the  whole  penis  becomes  of  a  dusky-red 
color,  and  the  appearances  presented  are 

,  P  -it  -i  Chancroidal  phimosis  with  Indian-club- 

those  of  a  very  actively  destructive  sub-  shaped  penis  and  destruction  of  the 

preputial  inflammation.     This  condition  distal  part  of  the  prepuce, 

is  in  striking  contrast  with  the  cold,  rather  unprogressive,  course  of 
phimosis  from  hard  chancres.  In  many  cases  of  chancroidal  phimosis 
there  is  a  complicating  chancroidal  bubo  in  the  groin. 

Chancroidal  Paraphimosis. — This  is  a  rather  rare  affection,  and 
is  quite  rebellious  to  treatment.  Chancroidal  paraphimosis  is  usually 
developed  in  cases  of  chancroidal  phimosis  by  the  violent  retraction 
of  the  prepuce,  which  then  cannot  be  pushed  forward.  The  case  then 
becomes  one  of  paraphimosis  complicated  by  chancroidal  ulcers  and 
much  oedema. 


INFLAMMATORY  AND  CHANCROIDAL  BUBOES. 

Seeing  that  the  majority  of  inflammatory  buboes  are  due  to  chan- 
croids and  to  mild  ulcerative  lesions  of  the  genitals  and  anal  region,  it 
is  well  to  consider  these  two  forms  of  abscess  together  in  this  place. 

Undoubtedly,   many  mild   inflammatory  swellings  of  the   inguinal 


448  THE  CHANCROID. 

ganglia  are  the  results  of  trifling  irritation  and  suppurating  processes 
on  the  toes,  legs,  scrotum,  penis,  and  anal  region.  It  maybe  that  these 
local  lesions  are  very  mild  and  ephemeral,  but  in  their  short  life  they 
give  off  sufficient  poisonous  secretion  to  cause  more  or  less  inflammatory 
reaction  in  the  crural  and  inguinal  ganglia.  Now,  there  may  be  in  the 
regions  just  mentioned  more  severe  inflammatory  processes,  in  which 
the  potentiality  of  the  poisoning  dose  is  greater,  and,  as  a  consequence 
there  is  true  suppuration  in  the  ganglia  of  the  groin.  Undoubtedly,  a 
large  proportion  of  the  suppurating  buboes  which  we  see  in  dispensary 
and  hospital  practice  is  caused  by  genital  and  extragenital  inflammatory 
lesions  of  which  the  patient  can  give  little  if  any  information. 

In  practice  we  find  four  well-marked  varieties  or  gradations  of  in- 
flammatory bubo,  which  are  as  follows  : 

1.  Simple  hyperplasia  of  one  or  more  ganglia — mono-ganglionic  and 
poly-ganglionic  adenitis,  which  may  be  acute  or  chronic.  These  lesions 
are  due  to  a  mild  irritative  process  which  shows  itself  by  enlargement 
of  the  inguinal  ganglia  and  swelling  of  the  parts,  which  may  be  of 
normal  color  or  of  a  more  or  less  deep  red.  Pain  may  or  may  not  be 
present.  In  these  cases  spontaneous  resolution  may  or  may  not  occur. 
Not  uncommonly  the  ganglia  are  left  in  a  permanently  phlegmasic 
or  hyperplastic  condition.  In  some  instances  these  swellings  run  a 
chronic  course,  and  later  on  break  down  and  suppurate,  in  which  condi- 
tions they  were  once  called  strumous  buboes. 

2.  Suppuration  of  one  or  many  ganglia  and  of  the  ambient  connec- 
tive tissue,  while  some  ganglia  still  remain  in  a  hyperplastic  condition. 
In  this  mixed  condition  some  of  the  ganglia  have  not  been  sufficiently 
disorganized  to  become  the  seat  of  suppuration,  and  they  remain  in  a 
state  of  low  inflammation  which  tends  to  prolong  the  life  of  the  bubo. 
When  one  or  more  ganglia  are  the  seat  of  suppuration,  and  others  of 
hyperplasia,  a  red  and  painful  swelling  is  found  in  the  groin,  and  digital 
examination  shows  a  combination  of  fluctuation,  doughy  sensation,  and 
nodulation.  This  mixed  form  of  bubo  may  be  as  large  as  an  egg  or 
even  larger.  In  this  form  of  bubo  the  morbid  process  just  falls  short 
of  that  which  occurs  in  the  suppurating  bubo. 

3.  Suppuration  of  the  whole  mass  of  ganglia  and  the  formation  of 
an  abscess-cavity.  The  true  suppurating  bubo  shows  itself  by  a  round 
or  oval  red  and  painful  swelling,  which  is  much  elevated  and  has  an 
area  of  one  to  four  inches  or  even  larger,  its  long  axis  usually  corre- 
sponding to  the  fold  of  the  groin.  In  this  form  an  abscess-cavity  is 
soon  formed  and  fluctuation  is  readily  discovered. 

All  of  the  foregoing  forms  of  bubo  may  be  observed  in  cases  of 
chancroid  of  the  genitals  and  of  ulcerative  lesions  of  the  legs  and  toes. 

4.  In  contradistinction  to   these  comparatively  mild  forms  of  bubo, 


DIAGNOSIS.  449 

the  true  chancroidal  or  virulent  bubo,  which  nowadays  is  quite  rare, 
stands  out  with  marked  features.  These  virulent  buboes  are  generally 
caused  by  pus  from  very  active  and  destructive  chancroids  and  from 
mixed  chancres  in  which  the  initial  lesion  has  become  infected  with 
chancroidal  pus.  The  chancroidal  bubo  gives  evidence  from  the  first 
of  an  actively  destructive  process.  The  groin  becomes  red  and  swollen, 
and  a  perceptible  tumor  is  soon  developed.  The  skin  becomes  red, 
tense,  and  the  seat  of  much  pain.  Redness  gives  place  to  a  brownish- 
red  tint,  and  then  the  swelling,  which  is  considerably  salient,  presents 
decided  fluctuation.  The  abscess  either  bursts  from  ulceration  of  the 
skin  or  it  is  incised.  The  roof  of  this  cavity,  which  consists  of  thinned 
and  inflamed  skin,  then  promptly  melts  away  and  the  typical  chancroidal 
bubo-cavity  is  left.  This  cavity  is  usually  deep ;  its  base  is  anfractu- 
ous, covered  with  sloughy  tissue  of  a  dirty-brown  color,  over  which  is 
a  layer  of  unhealthy  pus.  The  edges  of  this  ulcer  (since  it  really  is 
one)  are  of  a  deep-red,  thickened,  and  decidedly  undermined.  When 
untreated  this  condition  leads  to  serious  destruction  of  the  penis,  and 
may  threaten  the  integrity  of  the  vessels  of  the  groin. 

Diagnosis. — In  various  stages  the  chancroid  may  be  mistaken  for 
herpes  progenitalis,  exulcerated  balanitis,  ulcerated  fissures  and  abra- 
sions, hard  chancres,  mucous  patches,  ulcerating  syphilides,  and  epithe- 
lioma. 

When  a  number  of  herpetic  vesicles  are  grouped  on  the  genitals  with 
their  polycyclic  outline,  their  shallow  and  superficially  ulcerated  surface, 
with  the  history  of  antecedent  pains,  their  diagnosis  is  easy.  In  cases 
in  which  there  is  much  inflammation  a  doubt  may  exist ;  but  while 
ulcerous  herpes  may  extend  deeper  into  the  tissues,  it  does  not,  as  a 
rule,  like  chancroid,  extend  peripherally  by  ulceration.  Herpetic  vesi- 
cles coalesce  because  they  are  so  closely  grouped  ;  chancroids  coalesce 
by  peripheral  extension  and  fusion  with  each  other.  A  single  herpetic 
vesicle  may  be  mistaken  for  a  chancroid,  but  observation  of  its  course 
for  a  day  or  two  will  settle  the  question  of  its  nature. 

Exulcerated  balanitis  is  commonly  readily  recognized.  Its  lesions 
begin  in  patches  much  larger  than  chancroidal  ulcers,  usually  with  a 
history  of  phimosis  or  of  inattention  to  cleanliness,  and  their  edges  are 
not  undermined,  nor  are  their  surfaces  ulcerated  or  worm-eaten,  but 
rather  smooth  and  velvety. 

Very  frequently  patients,  particularly  men,  are  much  exercised  over 
traumatic  fissures  and  abrasions.  When  much  inflammation  is  present 
a  reserved  diagnosis  may  be  made  ;  but  cooling  applications  will  cure  the 
simple  lesion,  whereas  the  chancroid  will  be  only  slightly  improved. 
Water  dressings  and  time  will  make  the  diagnosis  between  a  simple 

29 


450  THE  CHANCROID. 

lesion,  a  chancroid,  or  a  hard  chancre,  the  last  of  which  these  seemingly- 
simple  lesions  often  prove  to  be.  This  fact  cannot  be  kept  too  promi- 
nently in  mind. 

Mucous  patches  may  in  a  measure  resemble  chancroids  if  very  much 
irritated,  but  it  is  an  exceeding  rarity  to  see  them  present  the  typical 
appearance  of  the  chancroid.  Usually  their  mode  of  development,  size, 
situation,  their  well-marked  salience,  their  configuration,  peculiar  color, 
and  their  coexistence  with  a  history  of  syphilis  or  with  syphilitic  lesions 
point  out  their  specific  nature.  It  must  be  remembered  that  about  the 
genitals  of  both  sexes  mucous  patches  and  condylomata  lata  are  often 
much  irritated  and  give  issue  to  an  irritant  pus  which  is  auto-inoculable. 

Prognosis. — In  the  majority  of  cases  the  prognosis  of  chancroids  is 
good.  AVhen  intelligent  and  efficient  treatment  is  instituted  early  the 
affection  is  soon  cured.  If  the  lesion  is  superficial,  it  may  be  cured  in 
a  week  or  ten  days.  If  the  chancroid  has  extended  deeply  into  the 
mucous  membrane  or  skin,  involving  the  lymphatics,  the  cure  is  effected 
slowly ;  but  even  in  this  class  of  cases  healing  ought  to  occur  within 
a  month.  Old  chancroids  with  much  thickening  of  the  skin  may  be 
still  more  rebellious.  Carelessness  of  the  patient,  dissipated  habits, 
and  excessive  physical  exercise  render  a  prognosis  less  positive  and 
assuring. 

When  phimosis  or  paraphimosis  is  present  the  outlook  is  more  grave, 
since,  unless  the  patient  can  be  put  under  perfect  control  on  his  back, 
the  progress  of  the  case  will  be  inevitably  bad,  and  may  result  in  more 
or  less  loss  of  tissue  or  deformity  of  the  penis,  may  be  complicated  by 
severe  hemorrhage,  or  result  in  phagedena  or  gangrene.  Lymphangitis 
and  buboes  may  be  produced,  which  may  lay  a  patient  up  for  a  long 
time,  besides  entailing  upon  him  suffering  and  misery.  In  such  cases 
the  immunity  to  systemic  infection  enjoyed  by  the  patient  is  a  source 
of  much  comfort  to  him.  Chancroids  of  the  meatus  and  urethra  under 
unfavorable  circumstances  result  in  stricture. 

In  women  the  prognosis  of  chancroids  is  less  favorable,  even  in 
mild  cases,  than  in  men.  The  difficulties  of  properly  treating  them, 
unless  they  will  remain  in  bed  under  the  care  of  a  nurse  or  in  a  hos- 
pital, are  very  great.  The  conformation  of  their  parts,  the  presence  of 
normal  and  abnormal  secretions,  the  setbacks  caused  by  menstruation, 
and  the  difficulty  of  retaining  properly  the  dressings — all  tend  to  pro- 
long the  course  of  the  ulcers.  Further,  women,  as  a  rule,  are  not  docile 
patients. 

Phagedena  and  gangrene  are  usually  not  to  be  feared  early  in  the 
course  of  these  lesions.  In  private  practice  I  have  never  seen  them 
begin  in  an  uncomplicated  young  chancroid,  though  in  dispensaries  and 
hospitals,  and  among  the  squalid  poor  and  in  drunkards,  they  may 


TREATMENT.  451 

sometimes  be  seen.  There  is  usually,  in  these  cases,  a  history  of  in- 
judicious treatment,  particularly  of  improper  cauterization,  an  absence 
of  treatment  or  inattention  on  the  part  of  the  patient,  or  of  inacces- 
sibility of  the  ulcers  in  consequence  of  complications,  such  as  phimosis 
or  paraphimosis. 

Treatment. — The  most  efficient  prophylactic  measure  is  thorough 
cleansing  of  every  fold  and  recess  of  the  genitals.  In  the  treatment  of 
chancroid  it  is  important  to  know  what  not  to  do — namely,  not  to  give 
mercury  and  treat  the  case  as  one  of  syphilis  ;  not  to  cauterize  injudici- 
ously and  indiscriminately  ;  not  to  use  ointments  and  fatty  preparations  ; 
and  never  to  resort  to  excision.  Nothing  but  harm  can  follow  any  of 
these  procedures. 

Cauterization  of  chancroids  has  for  its  object  their  destruction  and 
transformation  into  simple  lesions.  To-day  this  treatment  is  not  largely 
followed,  owing  to  the  tendency  which  has  increased  within  the  past 
fifteen  years  to  limit  it  to  certain  cases.  The  agents  now  mostly 
used  are  nitric  acid  and  carbolic  acid. 

It  is  of  prime  importance  that  patients  suffering  from  chancroids 
should  be  kept  as  quiet  as  possible — that  they  should  rest  at  every  op- 
portunity, should  not  attempt  severe  muscular  exercise,  nor  walk, 
jump,  dance,  nor  ride  on  horseback.  Care  should  be  taken  that  fric- 
tion and  compression  of  the  penis  be  avoided.  Alcoholics  should  be 
uncompromisingly  interdicted,  and  plain  digestible  food  taken. 

The  most  rigid  attention  to  cleanliness  and  to  keeping  the  parts  dry 
is  necessary  during  the  course  of  chancroids. 

Destructive  cauterization  is  only  applicable  for  chancroids  in  the 
early  stage  and  before  the  ulcers  become  complicated  by  much  oedema. 
Before  using  it — in  fact,  before  making  any  application  to  chancroids — 
the  ulcers  and  the  surrounding  parts  should  be  thoroughly  cleansed  with 
soap  and  water,  and  then  well  irrigated  with  a  very  warm  or  hot  bi- 
chloride of  mercury  (1  :  2000  solution)  ;  or  peroxid  of  hydrogen  or  a 
hot  solution  of  boroformalin  (1  to  3  per  cent,  in  water),  or  a  lysol 
solution  of  the  same  strength  and  temperature.  No  chancroid  should 
be  thus  treated  which  cannot  be  thoroughly  exposed  and  afterward  care- 
fully dressed.  The  technique  of  applying  the  acid — and  in  most  cases 
liquid  carbolic  acid  answers  every  purpose — is  very  simple.  The  sur- 
face of  the  ulcer  must  be  carefully  dried,  after  having  been  cocainized, 
and  then  the  acid  thoroughly  applied  by  means  of  a  bit  of  absorbent 
cotton  wound  around  the  end  of  a  wooden  toothpick.  Care  must  be 
taken  that  the  undermined  edge  is  thoroughly  touched,  and  that  none 
of  the  liquid  escapes  on  the  surrounding  parts. 

When  the  chancroidal  film  of  the  floor  of  the  ulcer  is  rather  thick,  it 
may  be  necessary  to  use  the  stronger  caustic  nitric  acid,  which  may  be 


452  THE  CHANCROID. 

done  in  the  manner  just  indicated ;  but  it  is  always  well  to  apply  first 
a  10  per  cent,  solution  of  muriate  of  cocaine.  By  this  means  the  patient 
suffers  no  pain,  and  the  surgeon  may  be  more  thorough  in  his  applica- 
tion. There  is  no  necessity  for  the  use  of  a  long  glass  stopper  or  of  a 
glass  rod  in  applying  nitric  acid,  since  it  can  be  done  much  more  per- 
fectly with  absorbent  cotton  on  the  end  of  a  wooden  toothpick.  It  is 
usually  well  for  a  few  hours  after  these  caustic  applications  to  apply 
water  dressing  or  lead-water  on  lint. 

Formalin  in  watery  solutions  (10  to  40  per  cent.),  sparingly  used 
once  or  twice  a  day  on  a  swab  of  absorbent  cotton,  is  a  very  useful 
remedy  in  sloughing  chancroids  and  in  open  chancroidal  buboes.  The 
parts  are  then  dried  and  one  of  the  powders  mentioned  later  may  be 
dusted  over  the  surface,  which  is  to  be  covered  writh  sterilized  gauze. 

The  actual  cautery  and  Paquelin's  thermocautery  are  very  efficient 
destructive  agents,  but  their  use  is  greatly  restricted  in  consequence  of 
the  dread  inspired  in  the  mind  of  the  patient  by  them.  Though  the 
parts  may  be  thoroughly  benumbed  by  cocaine,  few  persons  can  avoid 
shrinking  when  they  see  the  incandescent  wire  or  cauterizer. 

A  word  of  warning  is  necessary  against  the  use  of  the  stick  nitrate 
of  silver,  which,  unfortunately,  is  largely  used  by  the  laity  and  many 
physicians,  not  only  for  chancroids,  but  also  for  simple  fissures,  erosions, 
and  herpetic  vesicles.  This  agent  irritates,  while  it  does  not  destroy  ;  it 
intensifies  the  patient's  sufferings,  obscures  the  nature  of  the  lesion, 
rendering  diagnosis  impossible,  and  produces  so  much  inflammatory 
cedema  in  the  lesion  and  around  it  that  it  is  frequently  mistaken  for  a 
hard  chancre.     Its  use  is  to  be  emphatically  condemned. 

Treatment  Subsequent  to  Cauterization. — Such  is  the  super- 
ficial action  of  carbolic  acid  when  delicately  applied  that  under  proper 
conditions  no  inflammatory  reaction  is  to  be  feared.  With  nitric  acid, 
on  the  contrary,  unless  temporary  water  or  lead-water  dressings  are 
used,  there  is  danger  of  producing  subchancroidal  and  circumferential 
cedema  and  cell-infiltration.  This  is  a  complication  much  to  be  avoided, 
since  it  inevitably  retards  the  cure.  It  is  also  very  necessary  in  any 
case  in  which  several  chancroids — or  even  one  of  large  size — have  been 
cauterized  that  the  patient  should  remain  in  the  recumbent  position 
from  a  half  to  a  whole  day. 

For  chancroids  upon  the  glans  and  prepuce  and  in  the  vulva  the 
interposition  of  pledgets  of  lint,  sterilized  gauze,  or  absorbent  cotton  is 
necessary.  Whatever  application  is  used,  it  should  be  changed  at  short 
intervals  and  directly  destroyed,  preferably  by  fire.  Care  must  be  ex- 
ercised that  the  parts  be  not  wounded  in  changing  dressings.  In  addi- 
tion, patients  should  be  instructed  to  wash  very  carefully  the  parts, 
using  a  little  tuft  of  absorbent  cotton  with  soap  and  warm  water,  and 


TREATMENT.  453 

then  thoroughly  immerse  them  in  a  sublimate  solution  (1  :  2000).  For 
women  too  much  insistence  upon  cleanliness  is  not  possible,  since  they, 
even  the  most  cleanly  of  them,  are  liable  to  be  derelict.  They  should 
be  instructed  to  irrigate  thoroughly  and  copiously  the  vagina  several 
times  daily  with  a  mild  and  hot  aikaline  solution  (borax  or  supercar- 
bonate  of  sodium,  oSS,  to  water,  one  quart),  followed  by  a  hot  solution 
of  sublimate  (1  :  5000). 

The  most  efficient  all-round  application  to  chancroids  is  iodoform, 
since  it  is  an  undoubted  promoter  of  healthy  granulations  and  a  local 
sedative.  It  should  only  be  employed  in  the  form  of  an  impalpable 
powder,  either  pure  or  in  combination  with  some  bland  and  absorbent 
powder,  such  as  subnitrate  of  bismuth,  starch,  magnesia,  boracic  acid, 
or  powdered  sugar  of  milk.  Its  odor  is  its  great  drawback,  but  even 
in  private  practice  the  expedients  of  the  patient  or  surgeon  may  be 
such  that  its  use  does  not  compromise  the  former.  Various  essential 
oils  are  mixed  with  it,  but,  after  all,  coumarin,  the  active  principle  of 
Tonka  beans,  is  yet  the  best  disguise.  Powdered  roasted  coffee  also  is 
good.  When  used  in  powder  form  the  ulcerated  surface  should  be  freely 
but  not  copiously  dusted  with  it,  and  over  it  a  thickness  of  perfumed 
lint  or  absorbent  cotton  may  be  placed.  It  may  be  employed  suspended 
in  sulphuric  ether  (,3ss-oj  to  sj)  or  in  similar  proportions  in  glycerin, 
3ij,  water,  gyj. 

It  is  important  to  remember  that  the  action  of  iodoform  is  that  of 
producing  healthy  granulations,  and  that  when  this  has  been  effected  its 
use  should  be  suspended,  since  upon  granulating  surfaces  it  often  acts 
by  impeding  healing.  Further,  from  these  surfaces  it  is  liable  to  be 
absorbed  and  produce  toxic  effects  upon  the  skin  and  system  at  large. 
The  conclusion,  therefore,  warranted  is  that  the  use  of  iodoform  should 
be  suspended  when  chancroids  take  on  a  granulating  surface. 

While,  in  general,  iodoform  is  indicated  in  persistently  ulcerating 
and  chronic  chancroids,  we  have  several  valuable  drugs  for  application 
in  less  severe  cases,  namely  :  aristol,  europhen,  antinosine,  nosophen, 
resorcin,  and  acetanilid.  With  these  remedies  we  can  keep  the  surface 
of  the  ulcers  very  dry,  and  in  the  treatment  of  chancroids  the  dryer  we 
can  keep  the  surfaces  the  more  rapid  is  their  healing.  It  must  be 
borne  in  mind,  however,  that  it  is  well  to  irrigate  these  ulcers  at  least 
once  each  day,  and  then  to  dry  them  carefully  with  sterilized  gauze. 

In  the  cicatrizing  or  reparative  stage  of  chancroids,  not  earlier,  much 
progress  is  often  made  by  judicious  applications  of  a  solution  of  nitrate 
of  silver,  10  to  20  grains  to  the  ounce,  made  every  few  days.  The  parts 
are  prepared  by  careful  irrigation,  then  they  are  dried,  and  the  solution 
is  carefully  and  sparingly  applied. 

Curetting  of  chancroids  is  of  benefit,  and  is  indicated  when  the  ulcers 


454  THE  CHANCROID. 

are  old  and  the  seat  of  much  condensed  oedema.  It  is  also  beneficial  in 
cases  of  serpiginous  chancroid.  The  parts  to  be  operated  on  are  rendered 
as  clean  as  possible,  then  thoroughly  cocainized  and  curetted,  care  being 
taken  that  from  the  whole  surface  and  the  edges  of  the  ulcer  all  the 
diseased  tissue  and  detritus  are  removed. 

It  may  be  well  to  remember  that  in  some  cases  the  final  healing  of 
chancroids  may  be  brought  about  by  solutions  of  sulphate  of  zinc,  by 
aromatic  wine,  and  diluted  solution  of  chlorinate  of  sodinum. 

The  seat  of  chancroids  materially  modifies  the  method  of  treatment. 
For  lesions  under  the  prepuce  dry  powders  may  be  used,  and  great  care 
must  be  taken  to  avoid  oedema,  which  brings  in  its  train  phimosis  and 
paraphimosis,  two  very  annoying  and  serious  complications.  On  the 
integument  it  is  often  difficult  to  keep  dry  powders  on  the  ulcers,  in 
which  case  watery  applications  may  be  used,  or  powders  covered  over 
with  lint,  cotton,  or  gauze  moistened  with  water. 

At  the  frsenum  chancroids  are  prone  to  become  the  seat  of  oedema,  to 
hemorrhage,  to  eat  through  the  base  of  the  bridle  itself.  Therefore  they 
require  especial  care,  particularly  as  oedema  in  this  region  is  always  fol- 
lowed by  phimosis,  even  if  the  prepuce  is  ample. 

Chancroids  at  the  margin  of  or  within  the  urethra  must  also  be  care- 
fully treated,  and  it  is  well  to  avoid  cauterization,  since  it  is  so  liable  to 
produce  oedema,  to  cause  the  ulcers  to  become  more  active,  and  even  to 
result  in  stricture. 

If  .the  chancroids  are  just  at  the  lips  of  the  meatus,  they  should  be 
well  irrigated  with  a  hot  bichloride  solution  (1  :  2000)  or  carbolic  acid 
solution  (1 :  250  to  1 :  500).  After  drying,  the  parts  should  be  covered 
with  iodoform  or  aristol,  and  then  well  bandaged  with  a  mass  of  ab- 
sorbent cotton  carefully  retained. 

If  the  chancroids  are  about  an  inch  down  the  urethra,  the  parts 
should  be  first  irrigated  with  the  solutions  just  mentioned.  Then  a  No. 
12  French  catheter,  cut  off  at  a  length  of  four  inches  and  lubricated 
with  glycerin,  should  be  passed  into  the  urethra  beyond  the  ulcers,  and 
then  by  attachment  with  an  irrigator  fully  a  quart  of  the  antiseptic 
solutions  mentioned  should  be  retrojected.  Then  iodoform  or  aristol  is 
insufflated  into  the  urethra,  which  is  packed  with  absorbent  cotton. 

Chancroids  under  the  prepuce  must  be  treated  after  the  manner  of 
phimosis  plus  that  of  destructive  ulceration.  Subpreputial  injections 
of  hot  (1:  2000)  sublimate  solution  should  be  used  very  often,  taking 
care  to  get  the  irrigating  liquid  well  behind  the  glans.  Then  iodoform 
suspended  in  glycerin  and  water  should  be  introduced.  It  is  better  in 
all  cases  to  anticipate  gangrene,  and  if  the  progress  in  treatment  is  not 
perfectly  satisfactory  to  treat  the  case  surgically. 

Chancroids  in  women  demand  the  utmost  attention  to  cleanliness, 


TREATMENT.  455 

much  prudence  and  care  in  cauterization,  and  thorough  and  frequent 
dressings.  Their  surfaces  should  be  kept  free  from  discharges,  and  all 
coapting  parts  should  be  separated.  In  like  manner,  chancroids  of  the 
anus  must  not  be  injudiciously  cauterized  ;  they  should  be  carefully 
dressed,  the  parts  being  separated.  Attention  should  be  paid  that  the 
stools  be  rendered  liquid  in  consistence. 

Since  the  era  of  violent  and  indiscriminate  cauterization  has  departed 
and  iodoform  has  come  into  use,  the  ravages  of  serpiginous  chancroids, 
phagedena,  and  gangrene  are  much  less  common  and  less  severe  than 
formerly. 

The  treatment  of  serpiginous  chancroids  should  be  both  local  and 
general.  Wherever  there  is  debility  it  is  to  be  combated  with  nutritious 
food,  tonics,  and,  if  necessary,  stimulants.  Locally,  after  prolonged 
immersions  of  the  parts  in  water  as  hot  as  can  be  borne  and  irrigations 
with  1  :  2000  hot  sublimate  solutions,  the  surface  may  be  touched  with 
nitric  acid  or  bromide  and  glycerin  (1 :  8),  care  being  taken  that  the 
ulcerating  furrow  at  the  edge  be  thoroughly  touched.  The  whole  may 
be  temporarily  covered  with  lint  or  absorbent  cotton  moistened  with 
dilute  Labarraque's  solution,  1  :  10  of  water.  After  this,  iodoform 
may  be  applied  quite  freely,  and  the  whole  surface  covered  with  ab- 
sorbent or  iodoform  gauze,  over  which  is  a  layer  of  gutta-percha  tissue. 
While  this  treatment  is  usually  successful,  cases  do  occur  which  tax 
the  resources  of  the  surgeon  and  call  in  play  all  manner  of  therapeutical 
expedients  in  the  way  of  remedies  and  methods  of  application.  In 
some  cases  the  systematic  use  of  the  curette,  particularly  at  the  margin 
of  the  ulcer,  produces  good  results. 

Phagedenic  chancroids  require  the  most  careful  attention  to  diet, 
hygiene,  and  surroundings.  The  vital  powers  must  be  sustained  by 
tonics  and  stimulants,  and  opium  must  be  given  to  relieve  the  pain 
and  quiet  the  nervous  anxiety  of  the  sufferer.  The  next  essential  is 
to  determine  whether  syphilis  is  a  factor  in  the  process,  since  in  pro- 
portion as  that  diathesis  is  active  in  such  case  so  is  mercury  beneficial, 
whereas  it  is  positively  injurious  in  simple  phagedenic  chancroids.  In 
this  complication  the  dermal  curette  may  be  employed  with  benefit  to 
remove  debris  of  tissue,  sloughs,  and  pultaceous  matter  from  the  surface 
and  edges.  Then  the  whole  surface  may  be  thoroughly  but  carefullv 
touched  with  nitric  acid,  with  the  bromine  solution  (1 : 3)  of  glycerin, 
or  with  the  actual  cautery,  care  being  exercised  that  the  surrounding 
parts  are  not  injured.  Phagedena  com  plica  ting  chancroidal  phimosis 
necessitates  incisions  sufficiently  extensive  to  allow  the  parts  to  be 
reached.  In  addition  to  this  direct  medication,  the  most  important 
measure  is  the  immersion  of  the  parts  or  of  the  whole  body  in  a  hot 
sitz-bath  (98°  to  102°  F.)  for  from  eight  to  twelve  hours  a  day,  care 


456 


THE  CHANCROID. 


being  taken  that  the  comfort  of  the  patient  is  attended  to  in  every 
particular. 

Where  the  phagedena  attacks  the  distal  portion  of  the  penis  copious 
irrigations  of  hot  water  or  of  hot  sublimate  solution  (1  :  2000)  by  means 
of  a  spray  syringe  for  several  hours  a  day,  have  proved  very  efficacious 
in  my  hands.  When  healthy  granulations  appear  the  surfaces  may  be 
dressed  with  balsam  of  Peru  and  covered  with  sterilized  gauze. 

Treatment  of  Chancroidal  Phimosis. — In  the  treatment  of 
chancroidal  phimosis,  and  of  the  phimosis  which  sometimes  complicates 

Fig.  116. 


Chancroidal  phimosis,  showing  the  results  of  the  dorsal  incision. 

hard  chancres,  the  great  bugbear  in  the  past  has  been  the  fear  of 
infecting  the  incised  surfaces.  This  fear  has  led  to  delay,  to  the 
use  of  inefficient  methods  of  treatment,  and  in  many  cases  to  the 
destruction  of  large  portions  of  the  penis.  Such  a  fear  is  entirely 
groundless,  since  the  truth  is,  that  when  properly  treated  by  incision 
these  cases  begin  to  improve  at  once,  and  in  the  end  come  out  well. 
The  rule,  therefore,  in  these  cases  should  be  that  when  such  tentative 


TREA  TMENT.  457 

measures  as  hot  antiseptic  injections  and  immersions  in  hot  borax  and 
carbolic  solution  have  failed,  and  it  is  evident  that  the  subpreputial 
lesions  are  inaccessible  to  treatment,  even  before  evidences  of  perforation 
of  the  prepuce  are  to  be  seen,  the  parts  should  be  thoroughly  incised, 
so  that  they  may  be  inspected  at  will  and  properly  treated. 

The  old  operation  for  these  conditions  was  the  dorsal  incision,  which 
in  almost  every  case  utterly  fails  to  give  the  expected  relief.  This 
dorsal  incision,  even  if  sufficiently  long,  in  most  instances  gives  access 
to  only  the  most  prominent  portion  of  the  glans  penis,  while  the  fossae 
of  the  frsenura  and  the  coronal  sulcus  are  inaccessible  or  become  so  in 
a  day  or  two  after  the  operation.  When  the  dorsal  incision  is  made  in 
most  cases  the  condition  of  affairs  portrayed  from  life  in  Fig.  116  con- 
fronts the  surgeon,  in  which,  though  a  long  cut  has  been  made,  the  ulcer- 
ations are  inaccessible  to  his  inspection  and  treatment.  I  am  convinced 
that  the  only  efficient  operation  is  the  one  devised  by  myself  many  years 
ago.  This  operation  is  simplicity  itself,  and  consists  of  two  lateral  in- 
cisions of  the  prepuce.  Prior  to  the  operation,  the  parts  having  been 
thoroughly  cocainized,  the  preputial  sac  or  cavity  should  be  thoroughly 
irrigated  with  carbolic  solution  (2  per  cent.)  or  sublimate  solution  (1 :  2000) ; 
the  hairy  parts  must  be  shaved  and  the  genital  region  rendered  as  nearly 
aseptic  as  possible.  It  is  necessary  to  remember  that  in  this  form  of 
phimosis  the  prepuce  becomes  very  much  elongated  by  reason  of  the 
inflammatory  oedema,  and  that  in  most  cases  the  glans  becomes  retracted, 
probably  pushed  back,  by  the  closeness  of  investment  of  the  thickened  and 

Fig. 117. 


Author's  phimosis  scissors. 


inflamed  prepuce.  The  penis  being  held  in  the  line  of  the  thighs  by  an 
assistant,  the  patient  being  on  his  back,  the  surgeon  introduces  the  lower 
or  flat  blade  of  my  phimosis  scissors  (see  Fig.  117,  which  resemble  the 
plaster-of-Paris  scissors)  well  back  to  the  bottom  of  the  coronal  sulcus  on 
one  side,  exactly  in  the  median  line.  The  scissors  must  be  held  firmly, 
and  some  force  may  be  necessary  to  bring  the  blades  together,  for  the 
tissues  are  usually  very  hard  and  brawny  and  show  a  tendency  to  resist 
and  slip  from  the  blades  ;  so  that  if  the  incision  is  not  sufficiently  deep 
to  render  the  coronal  sulcus  visible  and  accessible,  it  must  be  lengthened. 


458 


THE  CHANCROID. 


Fig.  118. 


This  being  done,  the  same  care  as  to  symmetry  and  to  being  in  the 
median    lateral    line    is   observed    in   the    incision   on   the    other    side. 

The  surgeon  then  has  full  access  to 
the  whole  of  the  glans,  the  sulcus, 
frsenal  fossae,  and  the  inner  layer  of  the 
prepuce.  This  is  shown  in  Fig.  118, 
in  which  the  glans  is  seen  to  resemble 
somewhat  a  bone-stump,  and  the  prepuce 
the  two  flaps,  in  a  case  of  amputation 
in  the  continuity  of  a  limb.  During 
the  operation  the  parts,  and  the  surgeon's 
hand  as  well,  should  be  continuously 
irrigated  with  hot  bichloride  solution 
(1  :  2000).  All  morbid  debris  should 
be  removed  by  means  of  the  curette,  and 
the  ulcers  should  be  made  as  clean  as  pos- 
sible. 

In  most  cases  it  is  well  to  turn  the  flaps 
back  upon  the  penis,  and  there  keep  them 
under  the  pressure  of  the  dressing,  which 
should  be  wet  bichloride  gauze  (1  :  5000). 
This  dressing,  besides  encircling  the  penis, 
should  be  placed  between  the  cut  sur- 
faces on  each  side.  This  dressing  may  be 
removed  in  about  twelve  hours,  when  the 
parts  should  be  irrigated  and  then  dusted 
with  iodoform  or  aristol,  gauze  again  placed 
between  the  flaps,  and  a  gauze  bandage 
applied  around  the  distal  part  of  the  penis 
as  firmly  as  can  be  borne.  Usually  the 
dressing  should  be  renewed  daily  after  very  copious  irrigation.  The 
ulcerated  lesions  will  begin  to  improve  at  once.  If  gangrene  or 
phagedena  has  been  present,  either  of  these  processes  will  be  promptly 
arrested,  and  the  raw  surfaces  will  give  no  trouble.  The  period  of 
healing  varies  in  different  cases,  but  in  general  its  length  is  two  or 
three  Aveeks.  When  the  parts  have  healed  the  flaps  will  be  found  to 
be  remarkably  short  considering  their  previous  length.  The  top  one 
may  be  simply  a  small  truncated  cone,  which  can  be  readily  cut  off 
by  a  straight  incision,  or,  if  it  is  thickened,  the  parts  may  be  cut  out 
by  two  elliptical  incisions,  which  should  be  continued  down  fully  half 
an  inch  or  deeper,  in  order  to  remove  redundant  inflammatory  tissue. 
In  the  same  way  the  under  flap  must  be  treated  by  incisions  in  elliptical 
or  curved  lines,  carried  well  down  to  remove  the  redundant  tissue.     It 


Chancroidal  phimosis,  showing  the 
long  flaps  held  back  and  the  com- 
plete exposure  of  the  inner  surface 
of  the  prepuce  and  the  whole  of 
the  glans  penis. 


TREATMENT.  459 

may  be  stated,  as  a  rule,  in  these  cases,  that  a  wedge-shaped  mass 
must  be  removed  from  the  lower  flap,  and  this  incision  should  be  in 
keeping  with  the  conformation  of  the  parts.  The  edges  of  the  flap- 
wounds  are  then  brought  together  with  silk  sutures  and  the  parts 
antiseptically  dressed.  Usually  healing  is  prompt,  and  in  the  end  a 
very  good  result  is  obtained.  This  lateral-flap  operation  is  really  one 
of  circumcision  in  two  stages.  When  there  has  been  much  destruction 
of  the  prepuce  and  glans  the  symmetry  of  the  parts  is  correspondingly 
impaired.  It  is  wonderful,  however,  to  see  in  some  cases  in  which  there 
has  been  much  loss  of  tissue  how  lavish  Nature  is  in  her  process  of 
repair. 

It  may  be  well  to  warn  young  practitioners  never  to  perform  full 
circumcision  in  cases  of  chancroidal  phimosis. 

Treatment  of  Chancroidal  Paraphimosis. — Chancroidal  para- 
phimosis requires  as  the  first  essential  in  treatment  frequent  irrigations 
of  the  penis  with  hot  2  per  cent,  carbolic  solution  or  1  :  2000  hot  sub- 
limate solution.  These  irrigations  should  be  long  continued  and 
thorough.  In  addition,  the  penis  should  be  immersed  several  times  a 
day  in  these  solutions.  Seeing  that  early  reduction  of  the  parts  would 
lead  to  phimosis,  it  is  well  to  take  especial  care  that  the  ulcers  are 
promptly  healed.  Iodoform,  kept  in  place  by  gauze  or  absorbent 
cotton,  may  be  very  effective.  It  is  well  to  refrain  from  cutting  if 
possible ;  but  if  the  constriction  tends  to  produce  strangulation,  the 
encircling  band  at  the  bottom  of  the  sulcus  must  be  cut  as  directed 
in  the  section  on  Paraphimosis.  (See  page  000.)  As  a  dressing  the  bi- 
chloride solution  (1:  2000)  also  may  be  very  beneficial.  But  in  every 
case  most  reliance  may  be  placed  on  the  irrigations  and  immersions. 
In  all  cases,  even  of  simple  paraphimosis,  in  which  there  is  tendency  to 
ulceration  or  gangrene  these  antiseptic  measures  should  also  be  adopted. 
Chancroidal  paraphimosis  very  often  leads  to  deformity  of  the  penis,  for 
which  partial  ablation  of  the  prepuce  or  circumcision  may  be  necessary. 

In  the  treatment  of  paraphimosis  due  to  hard  chancres  it  is  first 
necessary  to  reduce  the  hyperemia  by  immersions  of  the  organ  in  very 
hot  water;  then  the  penis  may  be  bandaged  quite  firmly  with  lint 
soaked  in  black  wash.  As  the  process  of  involution  occurs  a  plaster 
of  mercurial  ointment  may  be  bandaged  around  the  penis.  This  appli- 
cation, together  with  constitutional  treatment,  will  cause  resolution  in 
most  cases. 

Treatment  of  Buboes. —  Simple  hyperplasia  of  the  inguinal 
ganglia,  the  first  form  of  bubo,  may  disappear  by  resolution.  When 
there  are  much  heat  and  swelling  cold  applications,  such  as  the  ice- 
bag,  carefully  used,  lead-and-opium  wash,  and  lead  and  muriate  of 
ammonium    wash,    may  cause  a  subsidence  of  the  process.     In  some 


460  THE  CHANCROID. 

cases  a  fist-sized  mass  of  sterilized  gauze  may  be  firmly  bandaged  over 
the  tumor  and  kept  continuously  wet  with  bichloride  solution  (1 :  2000). 
Compression  by  means  of  a  compressed  sponge  of  absorbent  cotton  held 
firmly  in  place  by  a  spica  bandage  of  absorbent  gauze  sometimes  pro- 
duces excellent  results.  In  some  cases  the  daily  application  of  tincture 
of  iodine,  combined  with  pressure,  will  effect  a  cure.  Whenever  the 
patient  is  particularly  anxious  for  the  speedy  resolution  of  the  swellings 
cantharidal  collodion  may  be  painted  over  them,  and  the  resulting 
blister  should  be  kept  open  for  several  days.  This  treatment,  aided 
by  the  recumbent  position,  is  sometimes  very  effective. 

"  When  abortive  measures  fail  in  some  cases  of  inguinal  ganglionic 
hyperplasia  it  is  well  not  to  temporize,  but  to  resort  at  once  to  the  radical 
operation  of  total  extirpation.  The  operative  field  is  shaved  and  ren- 
dered surgically  clean  ;  then  a  long,  free  incision  is  made  parallel  with 
Poupart's  ligament  and  over  the  most  prominent  part  of  the  swelling. 
It  may  be  necessary  also  to  make  a  vertical  incision  in  order  to  have 
more  space  to  work  in.  This  vertical  incision  may  be  of  advantage  in 
drainage.  In  some  cases  the  nature  of  the  tumor  may  suggest  the 
propriety  of  making  a  curved  or  crescentic  incision  either  above  or 
below  Poupart's  ligament.  In  other  cases  it  may  be  well  to  make  a 
vertical  incision  for  drainage  purposes. 

When  the  parts  are  exposed,  all  the  glands,  even  if  seemingly 
healthy,  are  to  be  dissected  out.  In  this  operation  the  surgeon  may 
have  to  go  down  to  and  even  between  the  femoral  vessels.  He  should 
therefore  work  slowly  and  cautiously.  Tissues  should  never  be  violently 
torn.  The  ganglia  will  be  found  to  be  firm  oval  masses  as  large  as  a 
bean  and  larger,  and  will  be  readily  recognized  when  the  operator  has 
become  familiar  with  the  operation.     All  bleeding  vessels  must  be  tied. 

In  many  cases,  if  great  care  is  exercised  in  the  matter  of  antisepsis, 
a  clean  wound  is  produced  and  its  edges  may  be  sutured  (interrupted)  by 
gut.  It  may  be  well  in  some  cases  to  place  in  the  most  dependent  part 
of  the  wound  a  narrow  strip  of  sterilized  gutta-percha  tissue,  in  order 
to  facilitate  drainage.  In  those  cases  in  which  the  integument  is  much 
inflamed  and  infiltrated  it  may  be  best  to  pack  the  wound  with  steril- 
ized gauze  and  allow  it  to  granulate,  or  to  put  in  only  a  few  sutures. 
The  parts  then  should  be  well  bandaged  (spica)  with  sterilized  absorbent 
cotton  and  gauze.  By  this  procedure  primary  union  may  be  obtained, 
in  which  event  the  detention-time  of  the  patient  in  bed  is  materially 
shortened. 

The  treatment  of  the  second  form  of  bubo,  which  is  practically  an 
abscess-cavity  in  which  many  swollen  ganglia  remain  in  an  indolent 
condition,  is  precisely  that  just  detailed.  In  these  cases  we  should 
aim    to   get   primary    union    by    the    thorough  removal  of  all   glands 


TREATMENT.  461 

and  of  any  portions  of  skin  which  may  have  been  infected.  Further 
than  this  the  wound-cavity  must  be  thoroughly  and  continuously 
irrigated  during  operation  with  hot  saline  solution,  after  which  the 
skin  flaps  are  brought  together  in  the  manner  described  (vide  supra). 
The  parts  after  being  well  washed  with  peroxide  of  hydrogen  are  to  be 
freely  irrigated  with  bichloride  solution  (1  :  2000),  and  by  means  of  a 
curette  every  removable  particle  of  morbid  tissue  should  be  scraped  off, 
great  care  being  exercised  not  to  wound  the  vessels.  The  aim  is  to 
produce  as  nearly  as  possible  a  clean  wound-cavity.  The  parts  are  then 
stuffed  with  iodoform  gauze  and  firmly  bandaged.  In  these  cases  it  is 
well  to  remove  the  dressings  every  day  and  thoroughly  irrigate  the 
cavity,  and  again  pack  it  and  bandage  the  parts.  Later  on  balsam  of 
Peru  gauze  may  materially  hasten  the  healing  process. 

In  many  of  these  cases  it  will  be  evident  to  the  surgeon  that  he 
cannot  hope  for  primary  union.  He  then  resorts  to  packing  the  wound- 
cavity  with  iodoform  gauze,  and  firmly  bandages  the  parts.  The 
frequency  of  renewal  of  the  dressing  will  be  indicated  by  the 
progress  of  the  case.  After  a  few  days  of  this  treatment  the  cavity 
may  be  packed  with  balsam  of  Peru  gauze. 

For  all  suppurating  buboes  and  for  some  chancroidal  buboes  the 
following  treatment  is  more  efficient  and  productive  of  quick  healing  : 

1.  The  operative  field  is  shaved  and  rendered  surgically  clean.  2. 
A  few  drops  of  an  8  per  cent,  cocaine  solution  are  injected  beneath  the 
skin  where  the  puncture  is  to  be  made.  3.  A  straight,  sharp-pointed 
bistoury  is  thrust  well  into  the  most  prominent  part  of  the  mass  until  pus 
flows.  4.  All  of  the  pus  is  forced  out  through  this  opening  by  firm  but 
gentle  pressure,  as  this  procedure  is,  as  as  a  rule,  very  painful.  5.  The 
abscess-cavity  is  irrigated  with  pure  peroxide  of  hydrogen  until  it 
returns  practically  clear.  6.  It  is  then  irrigated  with  1  :  5000  bichlor- 
ide-of-mercury  solution,  all  of  which  is  carefully  squeezed  out.  7.  The 
now  thoroughly  cleansed  abscess-cavity  is  completely  filled  with  10  per 
cent,  iodoform  ointment  by  means  of  an  ordinary  conical  glass  syringe 
previously  warmed  in  hot  water,  and  a  finger  held  over  the  puncture 
until — 8.  A  cold  wet  bichloride  dressing  is  applied  with  a  fairly  firm 
spica  bandage.  The  cold  congeals  the  ointment  at  the  puncture,  and 
thus  prevents  its  escape  into  the  dressing. 

The  patient  should  be  kept  very  quiet  for  the  first  twenty-four  to 
forty-eight  hours,  in  bed  if  possible,  although  this  is  not  absolutely 
necessary. 

The  dressing  should  be  changed  at  the  end  of  three  or  four  days. 
It  is  not  often  necessary  to  repeat  the  processes  of  irrigation,  cleansing, 
and  injection. 

Though  it  has  been  claimed  that  buboes  are  cured  by  this  method 


462  THE  CHANCROID. 

in  six  or  eight  clays,  the  time  occupied  is  usually  between  ten  and 
twenty-one,  which  may  be  said  to  be  an  excellent  showing.  Besides 
this  advantage,  there  is  no  necessity  for  painful  applications  or  dressings, 
and  the  scar  left  is  usually  so  small  that  it  is  necessary  to  look  for  it 
very  closely  in  order  to  find  it. 

The  treatment  of  well-advanced  chancroidal  bubo  requires  great 
care  and  the  free  use  of  antiseptics.  If  perforation  of  the  skin  has 
not  yet  occurred,  the  treatment  just  detailed  may  be  employed  perhaps 
with  beneficial  results.  When  perforation  has  occurred  an  oblique  inci- 
sion through  the  length  of  the  tumor  should  be  made ;  and  if  a  pocket 
should  exist  pointing  to  the  groin,  a  vertical  incision  is  necessary. 


CHAPTER   XXIV. 

SYPHILIS. 

NATURE,  COURSE,  AND  PROGNOSIS. 

Syphilis  is  a  chronic  infectious  disease  which  begins  in  a  local 
lesion,  which  lesion  is  caused  by  some  morbid  secretion  or  virus  or  the 
blood  derived  from  a  previously  syphilitic  person.  Beginning  thus  as  a 
local  infection,  it  promptly  invades  the  whole  organism,  more  especially 
its  connective  tissue,  induces  inflammatory  processes  of  a  low  grade, 
and  gives  rise  to  a  low  form  of  cell-growth  called  granulation-tissue. 
Syphilitic  inflammation,  when  uncomplicated,  does  not  produce  pus. 
It  is  therefore  a  chronic  granulation-tissue  disease  of  protracted  and 
irregularly  intermittent  course,  which  in  some  respects  resembles  lep- 
rosy and  tuberculosis,. 

Syphilis  pursues  a  course  peculiar  to  itself.  In  its  early  stages  it 
presents  points  of  resemblance  in  its  evolution  and  course  to  the  exan- 
themata and  to  diphtheria,  but  here,  again,  many  features  are  absent 
which  are  necessary  to  make  the  simile  complete.  Syphilis  originates 
in  a  fixed  and  visible  infectious  secretion ;  the  exanthemata  likewise 
originate  in  a  volatile  or  fixed  infection  ;  they  have  periods  of  incuba- 
tion— syphilis  two,  the  exanthemata  one — which  are  followed  by  con- 
stitutional disturbance  and  fever,  syphilis  in  these  features  being  com- 
paratively mild.  Further,  they  all  have  extensive  integumentary  and 
mucous-membrane  lesions,  which  in  the  exanthemata  are  inflamma- 
tory during  their  whole  course,  while  in  syphilis  they  are  moderately 
hypersemic  and  essentially  proliferative.  In  diphtheria  there  is  a  dem- 
onstrable micro-organism  which  attacks  the  system  in  one  spot,  usually 
the  throat,  and  exceptionally  in  other  regions.  From  this  local  infec- 
tive focus  general  constitutional  symptoms  are  developed,  such  as  fever, 
headache,  pains  in  bones  and  joints,  neuralgias,  paralyses,  albuminuria, 
and,  in  some  cases,  generalized  exanthemata.  Thus  syphilis  resembles 
diphtheria  in  its  local  origin,  its  systemic  poisoning,  its  peripheral 
paralyses,  its  infectious  nephritis,  and  its  dermal  rashes. 

Syphilis  is  a  disease  of  such  protean  aspects  that  in  some  of  its  very 
numerous  phases  it  presents  points  of  resemblance  more  or  less  strong 
to  almost  every  other  morbid  condition  or  disease.  Indeed,  the  meta- 
morphoses of  syphilis  are  infinite.  Reasoning  analogically,  with  the 
features  and    pathological    nature   of    leprosy,   tuberculosis,  the  exan- 

463 


464  SYPHILIS. 

themata,  and  diphtheria  in  mind,  one  is  forcibly  impressed  with  the  view 
that  syphilis  also  is  a  disease  of  microbic  origin  ;  but,  striking  as  is  the 
probability,  the  facts  in  our  possession  to-day  do  not  warrant  us  to  go 
as  far  as  some  authors  do  who  unhesitatingly  call  syphilis  a  disease  of 
bacterial  origin.  A  number  of  observers  have  found  in  active  and  early 
syphilitic  lesions  certain  micro-organisms  which  have  been  revealed  by 
delicate  staining-methods,  but  their  numbers  have  been  small,  their 
presence  not  absolutely  constant,  and,  furthermore,  no  cultures  have 
been  made,  and  consequently  inoculation-experiments  have  not  been 
tried. 

In  the  wide  range  of  infectious  diseases  we  uniformly  observe  local 
symptoms  due  to  the  microbes,  and  general  symptoms  resulting  from 
intoxication  produced  by  the  poisonous  secretions  or  toxins  developed 
by  them,  and  various  and  varied  tissue-changes.  Now,  in  syphilis  it  is 
very  probable  that  the  initial  lesion  with  its  tissue  peculiarities  is  the 
result  of  the  action  of  certain  specific  virulent  microbes.  With  the 
development  of  the  lesion  it  is,  reasoning  on  analogical  evidence,  not 
doing  violence  to  probability  to  suppose  that  from  this  original  infec- 
tious focus  a  diffusible  poison  is  proliferated  which  gives  rise  to  such 
fugitive  and  ephemeral  affections  (usually  irritative)  as  meningeal  hyper- 
emia, disturbances  of  the  reflexes,  erythematous  rashes,  icterus,  and 
pains  in  the  muscles,  bones,  joints,  and  fascia?.  The  fever,  the  debility, 
the  nervous  disturbances,  the  anaemia  and  chlorosis  from  malnutrition, 
and  the  underlying  changes  in  the  blood,  diminution  in  the  proportion 
of  its  solid  elements  and  the  increase  in  the  number  of  leucocytes — all 
these  point  to  the  existence  of  an  intense  microbic  poison  which  has 
been'  diffused  throughout  the  system.  Superadded  to  these  constitutional 
manifestations  are  the  many  cell-changes  to  which  syphilis  always  gives 
rise.  In  the  present  state  of  knowledge  we  can  only  explain  these 
complex  morbid  conditions  and  processes — since  they  resemble  very 
closely,  and  even  exactly,  similar  ones  in  other  diseases  in  which  the 
existence  of  a  bacterium  is  absolutely  certain — by  assuming  that  they 
are  the  result  of  a  virus  animatum  the  micro-organism  of  which  is  un- 
known to  us. 

Whatever  may  be  its  origin,  syphilis  is  a  disease  sui  generis,  which 
stands  out  prominently  in  pathology  as  a  distinct  succession  of  corre- 
lated morbid  processes  which  may  resemble  many  or  all  other  morbid 
processes  and  diseases  in  part  or  in  whole,  but  which  is  essentially  dif- 
ferent from  them  all.  There  is  no  etiological  relation  whatever  between 
syphilis  and  chancroid. 

There  are  two  clearly  defined  forms  of  syphilitic  infection — the  one 
called  the  acquired  form,  which  begins  in  a  local  or  primary  lesion,  the 
hard  chancre  ;  and  the  other  the  hereditary,  incorrectly  called  the  con- 


NATURE,   COURSE,  AND  PROGNOSIS.  465 

genital,  form,  in  which  there  is  no  local  primary  lesion,  the  disease  usu- 
ally beginning  with  general  manifestations.  In  the  acquired  form  the 
infection  is  derived  from  a  person  previously  infected  in  whom  the  dis- 
ease is  active.  In  the  majority  of  cases  syphilis  is  contracted  in  the 
sexual  act,  and  for  this  reason  this  disease  is  classed  among  the  venereal 
diseases.  It  is  then  syphilis  of  genital  origin.  There  are,  however, 
many  instances  in  which  syphilis  is  not  contracted  in  coitus — for  exam- 
ple, from  kissing  a  syphilitic,  by  inoculation  in  operations  upon  and 
examinations  of  syphilitica,  and  from  contamination  from  any  article 
which  by  some  means  or  accident  may  be  smeared  with  the  syphilitic 
virus.  These  latter  forms,  in  which  the  infecting  lesion  is  seated  on 
other  sites  than  the  genital  organs,  are  termed  cases  of  extragenital 
syphilis,  and  from  the  fact  that  in  most  instances  there  is  no  moral 
transgression  or  erotic  origin  in  their  causation,  they  are  classed  under 
the  category  of  syphilis  insontium,  syphilis  of  the  innocents  or  unmerited 
syphilis. 

Acquired  syphilis  is  never  developed  spontaneously  :  its  virus  enters 
the  organism  at  the  point  of  infection,  and  always  begins  with  the  de- 
velopment of  a  local  lesion  called  the  chancre,  the  hard  or  Hunterian 
chancre,  the  infecting  chancre,  the  initial  sclerosis,  the.  initial  lesion,  the 
primitive  neoplasm,  and  the  primary  lesion. 

Syphilis,  therefore,  is  communicated  to  the  healthy  person  by  means 
of  the  diseased  secretions  of  a  person  suffering  from  that  disease,  and 
the  first  evidence  of  the  infection  is  shown  in  the  initial  lesion.  Man- 
kind alone  seems  susceptible  to  the  action  of  the  syphilitic  virus,  since 
experiments  upon  animals  have  clearly  shown  that  they  are  immune 
to  it. 

Hereditary  syphilis  is  that  form  in  which  the  infection  is  derived 
from  one  or  both  parents  who  are  the  victims  of  an  active  state  of  the 
disease  at  the  time  of  conception.  It  is  very  doubtful  whether  true 
syphilis  can  be  transmitted  to  the  child  during  gestation,  particularly  at 
its  late  period. 

For  purposes  of  clinical  description  and  for  various  therapeutic  con- 
siderations it  is  well  to  preserve  Ricord's  division  of  the  disease  into 
three  periods — the  primary,  the  secondary,  and  the  tertiary.  The  pri- 
mary period  or  stage  of  syphilis  is  divided  into  two  parts,  called  periods 
of  incubation.  The  first  period  of  incubation  is  the  time  which  elapses 
between  the  infecting  coitus  or  contamination  and  the  appearance  of  the 
hard  chancre.  The  second  period  of  incubation  includes  the  intervals 
of  time  between  the  appearance  of  the  initial  lesion  or  chancre  and  the 
evolution  of  secondary  manifestations.  The  secondary  stage  occupies 
the  first  year  or  two,  in  which  the  lesions  are  generalized,  rather  super- 
ficially seated,  and  of  tolerably  mild  nature  and  course.     The  tertiary 

30 


466  SYPHILIS. 

stage  begins  at  the  expiration  of  two  years,  and  perhaps  in  some  cases 
earlier,  and  is  peculiar  in  the  fact  that  its  lesions  are,  as  a  rule,  more 
localized  and  circumscribed,  but  are  deeper  seated  and  of  a  more  severe 
character. 

Though  this  division  is  oftentimes  chronologically  incorrect,  and 
though  anatomically  there  are  many  exceptions  to  it,  it  is  the  best  we 
have,  and  it  can  be  put  to  a  good  purpose  as  a  working  clinical  basis 
when  its  shortcomings  are  clearly  known.  Ricord's  division  assumes  a 
uniform  methodical  and  progressive  course  and  development  of  the  dis- 
ease, which,  however,  may  be  observed  in  some  cases  and  are  wanting 
in  others. 

In  many  cases  the  secondary  stage  is  quite  regular  and  the  morbid 
processes  develop  superficially  and  in  mild  form.  Then  in  due  time 
(the  disease  for  any  reason  being  progressive)  tertiary  symptoms  show 
themselves,  and  we  have  an  orderly  and  tolerably  systematic  evolution 
of  syphilis  from  the  primary  through  the  secondary  to  the  tertiary 
stage.  But  in  many  cases  there  is  a  want  of  uniformity  of  evolution, 
for  lesions  of  a  tertiary  character  appear  precociously  ;  they  may  coexist 
with  secondary  lesions,  and  not  infrequently  after  the  precocious  appear- 
ance of  tertiary  lesions  those  of  the  secondary  period  show  themselves. 
While,  therefore,  it  is  often  impossible  to  draw  sharp  lines  of  distinction 
between  a  secondary  and  a  tertiary  stage,  we  can  hold  fast  in  most  cases 
to  the  following  course  in  our  clinical  studies  and  in  regulating  our 
therapeutics — namely,  to  consider  superficial  lesions  of  the  skin  and 
mucous  membranes  and  various  systemic  symptoms  and  conditions 
known  to  be  of  early  development  as  evidences  of  the  secondary  period 
and  indicating  an  appropriate  treatment,  and  to  look  upon  deep-seated 
lesions  of  the  connective  tissues  and  those  of  bones  and  viscera  as  be- 
longing to  the  tertiary  period  and  requiring  treatment  for  advanced 
stages. 

The  mode  of  development  of  syphilis  in  its  primary  period  is  pecu- 
liarly precise  and  slow,  is  unattended  with  striking  features,  and  is 
nearly  always  quite  regular  in  its  course  and  chronology,  so  that  toler- 
ably clear  lines  may  be  laid  down  concerning  it. 

The  primary  stage  of  syphilis  begins  with  the  act  of  infection,  in 
which  the  virus  is  deposited  upon  some  portion  of  the  body,  genital 
or  extragenital.  In  the  vast  majority  of  cases  no  evidences  of  this  acci- 
dent is  seen,  and,  owing  to  various  causes,  such  as  promiscuousness  of 
sexual  contact,  indifference,  and  failure  of  memory,  in  many  cases  no 
precise  data  can  be  obtained  concerning  it.  From  the  date  of  infection 
a  period  of  time  elapses  before  any  visible  manifestation  of  syphilis 
shows  itself,  which  is  called  the  first  'period  of  incubation.  Clinical  ob- 
servations and  experimental  inoculations  enable  us  to  say  that  the  dura- 


NATURE,   COURSE,  AND  PROGNOSIS.  467 

tion  of  this  period  may  be,  in  very  exceptional  cases,  as  short  as  ten 
days  and  as  long  as  seventy  days.  I  myself  have  seen  undoubted 
instances  of  sixty  and  seventy  days'  primary  incubation.  In  general, 
however,  the  average  will  be  found  to  be  between  twelve  or  fifteen  and 
twenty-one  days.  At  the  expiration  of  this  time  the  hard  chancre  or 
initial  lesion  of  syphilis  shows  itself. 

It  must  be  remembered  that  there  is  no  haphazard  about  the  devel- 
opment of  the  chancre,  since  the  disease  always  begins  at  the  infected 
part,  which  is  commonly  the  genital  organs.  In  somewhat  rare  cases 
two  parts  of  the  body  may  be  infected  at  the  same  time.  Thus  we  may 
find  the  initial  lesion  of  the  penis  not  very  infrequently  coexistent  with 
a  similar  lesion  on  the  lip,  the  face,  the  finger,  or  other  parts  of  the 
body. 

With  the  appearance  of  the  hard  chancre  the  second  'period  of  incu- 
bation of  syphilis  begins,  but  not  the  secondary  stage  of  the  disease. 
This  period  is  rather  more  regular  than  the  first  period  of  incubation, 
and  lasts  usually  about  forty  or  forty-five  days,  sometimes  as  long  as 
sixty,  and  very  exceptionally  ninety  days.  Cases  of  longer  incubation 
than  just  stated  should  be  accepted  with  much  reserve  and  the  ele- 
ments of  fallibility  carefully  probed.  The  length  of  the  secondary 
period  of  incubation  may,  to  a  certain  extent,  be  modified  by  influences 
which  may  affect  the  circulation,  such  as  heat  and  alcoholics.  In 
general,  in  hot  weather  the  end  of  the  secondary  period  comes  quite 
promptly,  while  in  cold  weather  it  may  be  delayed.  In  weakly,  thin, 
and  anaemic  subjects  the  second  period  may  be  much  prolonged.  I  re- 
cently waited  for  the  evolution  of  secondary  manifestations  in  a  cadav- 
erous young  man  for  eighty-two  days  before  they  appeared.  In  the 
case  of  a  man  forty-three  years  old  the  first  period  of  incubation  was 
twenty-one  days.  On  the  forty-seventh  day  of  the  second  period  of 
incubation  he  was  attacked  with  severe  pleuropneumonia,  which  lasted 
thirty-one  days,  and  on  the  day  following  severe  general  syphilitic 
manifestations  showed  themselves.  In  this  case,  therefore,  the  secondary 
period  of  incubation  was  seventy-eight  days. 

The  morbid  phenomena  observed  during  this  period  of  incubation 
are  the  development  and  growth  of  the  initial  lesion  or  chancre,  and 
the  enlargement  of  the  inguinal  ganglia  in  immediate  anatomical  con- 
nection, which  becomes  appreciable  sometimes  as  early  as  the  fifth  day, 
but  usually  from  the  seventh  to  the  tenth.  In  some  cases  there  is  an 
induration  of  the  lymphatic  vessels  leading  from  the  chancre  to  the 
ganglia.  This  lymphatic  hyperplasia  goes  on  slowly  and  painlessly 
until  the  ganglia  become  much  enlarged.  These  two  periods  of  incu- 
bation, the  primary  and  the  secondary,  constitute  the  first  or  primary 
stage  of  syphilis,  which  may  occupy  in  its  evolution  from  sixty  to  ninety 


.468  SYPHILIS. 

days,  rarely  longer.  The  disease,  then,  may  be  said  to  have  become 
fully  developed,  and  at  this  date  general  systemic  manifestations  and 
symptoms  appear  which  constitute  what  is  called  secondary  syphilis. 

With  the  expiration  of  the  second  period  of  incubation,  or  that  of 
local  manifestations,  the  secondary  stage  of  syphilis — or,  as  it  is  called, 
the  stage  of  general  or  constitutional  manifestations  or  the  condylomatous 
stage — begins.  In  this  stage,  as  a  rule,  the  lesions  are  superficial,  and 
confined  largely  to  the  skin  and  mucous  membrane,  consisting  of 
erythematous,  papular,  and  pustular  rashes.  The  duration  of  the 
secondary  period  of  syphilis  cannot  be  definitely  stated,  since  it  depends 
largely  upon  the  condition  of  the  constitution  and  the  habits  of  the 
patient,  and  also  upon  the  fidelity  with  which  he  follows  treatment.  In 
the  vast  majority  of  cases — certainly  in  those  in  which  there  is  no 
organic  trouble — syphilis  proves  a  very  tractable  and  curable  disease, 
provided  patients  will  follow  treatment  in  a  careful  and  systematic 
manner  during  a  sufficient  period  of  time.  If  this  is  done,  the  disease 
may  end  with  the  secondary  stage,  the  patient  thereafter  remaining 
healthy. 

Prognosis. — In  many  diseases  of  microbic  origin  the  severity  of 
the  attack  depends  upon  the  activity  and  the  quantity  of  the  virus 
inoculated  or  received.  When  the  microbes  are  derived  from  active 
and  exuberant  lesions  they  usually  produce  an  intense  disease  in  vul- 
nerable subjects,  but  when  the  virus  is  attenuated  or  when  the  microbes 
are  in  -a  weakly  state  (involution-forms)  then  the  resulting  invasion 
is  less  severe.  To  these  features  offered  by  other  infectious  processes 
syphilis  does  not  seem  to  present  points  of  resemblance.  In  other 
words,  we  know  nothing  of  the  mildness  or  malignancy  of  the  syphilitic 
virus,  and  extended  clinical  observations  made  by  many  authorities  go 
to  show  that  a  virus  which  produces  severe  syphilis  in  one  individual 
may  produce  only  a  mild  form  of  the  disease  in  another.  Therefore,  in 
syphilis  it  may  be  said  without  fear  of  contradiction  that  the  potenti- 
ality of  the  poisonous  dose  is  about  the  same  whether  it  be  derived 
from  a  severe  case  of  syphilis,  or  from  a  mild  one.  In  the  light  of  our 
present  knowledge  it  seems  warrantable  to  state  that  there  is  a  well- 
marked  uniformity  in  the  infectious  quality  of  the  virus,  no  matter 
from  whom  it  may  be  derived,  and  that  this  poison  may  produce  in 
some  subjects  a  mild  and  in  others  a  severe  form  of  syphilis.  It, 
therefore,  logically  follows  that  the  benignity  or  severity  of  syphilis  is 
very  largely  determined  by  the  condition  of  the  individual.  The 
potency  of  the  virus  is  about  the  same,  whether  it  be  derived  from  the 
initial  lesion  or  secondary  lesion  or  the  blood. 

Clinical  observation  clearly  shows  that  in  some  patients,  owing  to 
partial  immunity,  the   syphilitic  poison    meets  with   such   resistance  on 


NATURE,    COURSE,   AND  PROGNOSIS.  469 

the  part  of  the  tissues  that  it  makes  but  a  slight  impression,  while  in 
others  a  marked  susceptibility  to  its  action  exists,  and  a  more  or  less 
severe  form  of  the  disease  is  produced.  It  has  been  claimed  that,  from 
certain  features  observed  in  the  chancre  and  during  its  course,  we  may 
draw  prognostic  points  as  to  the  mildness  or  severity  of  the  subsequent 
course  of  the  disease.  It  has  been  said  that  a  small,  slightly  indurated 
chancre  is  usually  followed  by  a  mild  attack  of  syphilis.  This  state- 
ment may  apply  to  some  cases,  but  certainly  not  to  the  majority.  It  is 
not  uncommon  to  see  all  grades  of  severe  syphilis  follow  an  insignificant 
initial  lesion  which  might  have  undergone  involution  in  ten  days  or  two 
weeks,  and  have  left  little,  if  any,  trace  upon  the  part  attacked.  It  is 
very  common  to  see  severe  and  extensive  syphilitic  lesions  in  persons 
who  never  knew  they  had  a  chancre,  and  in  whom  it  must  have  been 
very  small.  The  truth  is  that  both  mild  and  severe  grades  of  syphilis 
may  follow  small  initial  lesions.  It  has  also  been  claimed  that  large 
and  deep  primary  lesions  invariably  lead  to  severe  forms  of  infection, 
but  this  statement  is  only  partially  true,  since  cases  of  mild  syphilis 
occur  which  follow  a  very  extensive  chancre,  and  instances  in  which 
two  or  three  parts  of  the  body  were  the  seat  of  chancres  (penis,  lip, 
and  finger,  or  penis  and  lip,  or  other  part)  are  not  uncommon  in  which 
the  course  of  the  disease  was  not  at  all  severe. 

Ulceration,  phagedena,  and  gangrene,  attacking  the  initial  lesion, 
have  been  claimed  to  be  ominous  signs  of  a  severe  attack  of  syphilis. 
Extended  clinical  observation  shows  that  this  assumption  is  not  fully 
warranted.  Destructive  ulceration  of  any  form  or  gangrene  attacking 
the  initial  lesion  is  always  the  result  of  contamination  with  pyogenic 
microbes,  usually  caused  by  carelessness  and  uncleanliness  and  also  by 
intemperate  cauterization,  and  they  are  to  be  regarded  as  disquieting 
accidents  and  not  as  indices  of  the  malignancy  of  the  initial  lesion  or  as 
forecasting  a  severe  attack  of  syphilis.  In  some  cases  of  phagedena  and 
ulceration  of  the  initial  lesion  a  temporary  condition  of  ill-health  is  pro- 
duced, but  careful  treatment  will  soon  remove  this  accidental  compli- 
cation. It  is  also  claimed  by  some  authors  that  extragenital  chancres 
are  the  forerunners  of  severe  syphilis.  This  view  is  certainly  based  on 
the  observation  of  a  few  exceptional  cases,  and  is  not  borne  out  by  ex- 
tended investigation.  It  not  infrequently  happens  that  the  nature  of 
an  extragenital  chancre  is  not  recognized  or  that  it  runs  its  course 
unobserved  by  the  patient.  In  such  cases  the  resulting  syphilis  may 
not  be  treated,  or  it  may  be  improperly  treated,  and  then  a  severe  attack 
may  result. 

Fortunately  for  the  human  race,  syphilis  in  the  great  majority  of 
cases  is  contracted  by  young  men  and  women  between  twenty  and  forty 
years  of  age  in  whom  the  vital  processes  are  active  and  whose  health,  as 


470  SYPHILIS. 

a  rule,  is  good.  Such  patients  are  naturally  capable  of  withstanding 
attacks  of  various  diseases,  but  some  are  more  resistant  than  others. 
According  to  my  observations  it  may  be  said  that  syphilis  is  much  less 
severe  to-day  than  it  was  thirty  years  ago.  We  no  longer,  not  even  in 
large  syphilitic  clinics,  see  so  many  cases  of  malignant,  of  severe,  and 
of  malignant  precocious  syphilis,  nor  do  we  meet  with  the  more  profound 
and  grave  tertiary  lesions  by  any  means  as  frequently  as  we  did  a 
quarter  of  a  century  ago.  This  diminution  in  the  severity  of  the  disease 
is  largely  due  to  our  improved  methods  of  treatment,  to  better  sanitary 
and  nutritive  conditions,  and  to  the  greater  attention  which  is  paid  to 
cleanliness  and  antisepsis.  But  further  than  this,  there  undoubtedly 
exists  to-day  in  the  tissues  of  many  individuals  a  greater  resistance  to 
syphilitic  infection  than  was  possessed  years  ago.  In  other  words,  in 
many  people  a  moderate  condition  of  immunity  against  syphilis  exists, 
which  is  due  to  the  changes  in  the  tissues  and  perhaps  in  the  blood  in- 
duced by  syphilis  in  their  more  or  less  remote  ancestors. 

In  a  general  way  it  may  be  stated  that  the  larger  number  of  persons 
who  contract  syphilis  are  those  who  are  in  average  good  health  and  have 
not  grown  old.  In  a  smaller  number  the  standard  of  health  is  less  high, 
and  in  many  patients  certain  morbid  conditions  exist  which  are  due 
either  to  disease  or  bad  habits,  and  which  lower  their  power  of  resist- 
ance. Syphilis  when  untreated  by  mercurials  generally  runs  a  quite 
uniform  course,  in  which  the  early  superficial  lesions  are  followed  by 
deeper  -and  more  severe  manifestations.  Its  tendency,  luckily  for  man- 
kind, is  to  expend  its  force  on  the  superfices  of  the  body,  and  it  seems 
very  probable,  particularly  in  healthy  subjects,  that  the  lesions  of  the 
deeper  parts  are,  in  the  main,  due  to  various  determining  causes,  such 
as  traumatisms  (bones,  joints,  tendons,  and  fascise),  antecedent  pathologic 
processes  (liver,  spleen,  kidneys,  intestines,  and  testes),  and  to  a  neuro- 
pathic tendency  (cerebrospinal  affections).  When  any  of  the  above- 
mentioned  causes  exist  in  untreated  syphilis,  the  grave  order  of  lesions 
may  follow  or  coexist  with  the  more  superficial  ones.  Some  of  these 
mild  cases,  in  persons  previously  healthy,  sooner  or  later  become  grave, 
and  even  malignant ;  but  in  general  the  gravity  or  malignancy  of  syphilis 
is  due  to  some  inherent  defect  in  the  constitution  of  the  patient,  to  some 
diseased  condition,  or  to  a  lowered  state  of  health  due  to  privation  or 
bad  habits. 

The  pathology  of  early  syphilis  is  revealed  to  us  in  the  cell-infiltra- 
tions constituting  the  essential  lesions  which  are  distributed  in  a  sym- 
metrical manner  over  the  whole  body.  With  the  evolution  of  this  new 
growth  a  diffusible  poison  is  developed,  as  we  have  already  seen,  Avhich 
is  carried  throughout  the  entire  system  and  gives  rise  to  the  various 
phenomena  (fever,  debility,  emaciation,  headaches,  neuralgias,  arthralgias, 


NATURE,    COURSE,  AND  PROGNOSIS.  471 

periosteal  pains,  splenic  engorgement,  and  sometimes  pleuritis).  In  con- 
sequence of  the  destruction  of  the  newly-formed  cells  by  treatment  the 
tangible  lesions  undergo  involution  and  disappear,  and  in  proportion  to 
the  completeness  of  their  cure  does  the  poison  secreted  by  them  grow  less 
and  less  in  potency  and  quantity.  When  a  perfect  cure  does  not  take 
place,  some  of  these  morbid  cells  remain  (in  all  probability  in  little 
masses  around  the  bloodvessels,  and  not  stored  in  the  ganglia),  but  as 
they  grow  old  they  lose  their  vitality  and  increase  slowly,  and,  having 
lost  much  of  their  virulency,  produce  very  little,  if  any,  of  the  diffusible 
poison.  This  is  what  takes  place  in  tertiary  syphilis,  in  which  the 
new  growths  are  indolent,  aphlegmasic,  and  show  a  marked  tendency 
to  localization  and  to  asymmetrical  distribution.  The  gumma  is  the 
direct  and  feeble  descendant  of  the  virulent  round-cell  infiltration  of  the 
secondary  stage  of  syphilis.  Such,  in  brief,  is  the  nature  and  extent  of 
the  syphilitic  invasion,  which,  if  unchecked,  goes  on  more  or  less  rapidly 
to  produce  tissue-change,  to  lower  the  standard  of  vitality,  to  attack 
organs  whose  integrity  is  essential  to  life  and  happiness,  and  to  produce 
serious  conditions,  and  even  death. 

Syphilis  in  healthy  persons,  male  and  female,  as  a  rule,  runs  a  mild 
course,  and  its  poison  is  eliminated  from  the  system  if  active  treatment 
is  instituted  at  the  proper  time.  Much  depends  upon  the  intelligence 
and  docility  of  the  patient,  who,  if  he  enjoys  ordinary  good  health 
and  will  follow  up  energetic,  but  very  carefully  directed,  treatment, 
may,  I  am  confident,  be  cured.  This  comforting  assurance  may  be 
given  to  the  majority  of  patients  seen  in'  private  practice,  who,  in 
general,  are  intelligent,  realize  the  gravity  of  their  condition,  and 
resolve  so  to  conduct  themselves  and  regulate  their  habits  that  their 
vital  processes  can  resist  the  depressing  influences  of  the  syphilitic 
poison  and  be  able  to  undergo  the  strain  put  upon  them  by  long- 
continued  medication.  Thirty  years'  study  and  observation  of  the 
nature  and  treatment  of  syphilis  has  convinced  me  that  in  most  cases 
a  cure  is  possible,  whereas,  in  years  gone  by,  we  groped  in  ignorance, 
pursued  faulty,  and  even  harmful,  therapeutic  methods,  and  never  felt 
ourselves  masters  of  this  insidious  and  far-reaching:  infection. 

Vigorous  and  intelligent  treatment  more  or  less  promptly  influences 
and  attenuates  the  virulent  infection,  which  will  gradually  subside, 
and  in  most  cases  in  previously  healthy  persons  a  cure  will  result  within 
two  or  three  years,  and  in  some  cases  much  sooner.  The  mercury 
destroys  the  newly-formed  and  nascent  cells,  and  as  they  die  so  does 
their  poisonous  power  wane.  In  many  cases  we  see  no  visible  lesions 
or  very  simple  ones  after  the  first  rash.  Cases  thus  treated  mav  be 
called  mild,  and  in  private  practice  it  is  the  rule,  when  patients  are 
intelligent  and  docile,  and  submit  fully  to  treatment,  to  see  this  benign 


472  SYPHILIS. 

course  of  syphilis.  Such  cases  may,  therefore,  be  taken  as  the  standard 
of  comparison  with  other  forms  of  syphilis  now  to  be  considered. 

There  are  many  persons  who,  though  not  absolutely  sick,  are  not 
really  well.  In  this  category  are  included  cases  of  anaemia,  flabby  and 
poorly  nourished  individuals,  blonds  with  light  reddish  hair,  persons 
suffering  with  malnutrition,  and  even  those  who  are  mildly  neurasthenic. 
Then  again  we  observe  cases  in  which  the  health  is  impaired  by  worry 
and  grief,  by  business  cares,  doubts,  dreads,  and  excitements,  also  by 
insomnia.  All  such  may  be  said  to  suffer  from  lowered  vitality,  and 
in  them  syphilis  is  apt  to  run  a  more  or  less  severe  course.  In  the 
treatment  of  these  cases  we  may  not  experience  the  quick  response  to 
the  administration  of  mercurials ;  the  manifestations  may  be  rather 
slow  in  disappearing,  and  they  may  show  a  tendency  to  reappear. 
The  cure,  therefore,  is  not  produced  quite  as  quickly  as  in  the  benign 
cases ;  but  although  the  case  may  hitch  and  halt,  neither  physician  nor 
patient  should  falter.  In  America,  syphilis  in  women  runs  about  the 
same  course  that  it  does  in  men,  but  the  female  sex  is  much  less  fre- 
quently attacked  by  cerebral  and  cerebrospinal  affections  than  are  men. 
Women,  as  a  rule,  are  less  addicted  to  alcoholics  than  males,  and  they 
are  not 'called  upon  to  overtax  the  brain  as  many  men  are,  consequently 
they  present  rather  infrequently  evidences  of  specific  nervous  affections. 

Syphilis  in  the  poor  and  ignorant  is  mild  or  severe,  and  sometimes 
malignant,  in  its.  course.  Perhaps  the  greatest  of  all  drawbacks  in  the 
treatment  of  syphilis  in  the  poor  is  to  establish  in  their  minds  a  real- 
izing sense  of  the  gravity  of  the  affection.  Consequently,  it  is  in  these 
individuals  that  we  often  see  the  disease  run  a  chronic  and  severe  course. 
They  are  careless  in  following  treatment,  and,  as  a  rule,  cannot  be  in- 
duced to  remain  under  medical  care  any  length  of  time  after  the  disap- 
pearance of  the  specific  lesions  or  the  cessation  of  their  discomforts. 
This  is  the  explanation  of  the  severity  and  malignancy  of  syphilis  among 
the  lower  orders  of  our  population.  Then,  again,  many  poor  people  are 
addicted  to  alcoholics,  which  act  harmfully  upon  them  and  render  the 
course  of  syphilis  severe  and  protracted.  In  this  class  of  patients  the 
food  is  very  commonly  inadequate  in  quantity,  of  poor  quality,  and 
among  many  (Italians,  Poles,  and  Hebrews)  fish  and  the  starchy  articles 
are  eaten  and  very  little,  if  any,  animal  food  is  used.  The  nutrition  of 
these  people  is  usually  below  par,  and  few  of  them  possess  that  systemic 
resistance  which  holds  them  up  when  in  the  grip  of  syphilis.  Then 
again  there  are  other  factors  which  tend  to  render  syphilis  severe  in  the 
lower  classes.  They  are  commonly  uncleanly,  and  as  a  result  the 
microbes  of  the  skin  act  upon  syphilitic  lesions  and  induce  in  them 
ulceration  and  perhaps  phagedena  and  gangrene.  While  in  private 
practice  it  is  very  rare  to  see  pustular  eruptions,  in  the  lower  classes 


COMPLICATIONS.  473 

these  lesions  are  very  common.  Then,  again,  nncleanliness  leads  to  the 
development  of  mucous  patches  and  condylomata  lata  upon  the  vulva, 
anus,  axillae,  umbilicus,  and  upon  other  parts,  and  these  lesions  aggra- 
vate and  lengthen  the  course  of  the  disease. 

Severe  forms  of  syphilis  are  observed  in  these  patients  in  varying 
grades  of  intensity.  As  a  rule,  the  secondary  lesions  are  numerous 
and  distributed  symmetrically  over  the  whole  body,  and  the  influence 
of  the  specific  poison  is  severe  (neuralgias,  headaches,  joint,  bone,  and 
muscular  pains,  etc.).  One  rash  runs  an  indolent  course  and  is  soon 
followed  by  one  of  more  severity  which  becomes  complicated  with 
pyogenic  infection,  and  thus  we  come  to  see  ecthyma,  impetigo,  and 
varioliform  syphilides  and  rupia.  In  these  cases  there  is  more  or  less 
prostration  and  little  reparative  tendency,  while  in  very  severe  cases 
fever,  sometimes  head  symptoms,  great  emaciation,  and  even  marasmus 
may  exist.  Then,  again,  in  unhealthy  persons,  particularly  in  the  lower 
orders,  we  may  observe  what  is  called  precocious  malignant  syphilis, 
which  is  an  entirely  different  condition  from  true  malignant  syphilis. 
Precocious  malignant  syphilis  is  noteworthy  for  the  reason  that  it  usu- 
ally begins  in  the  severer  forms  of  the  disease  in  which  ulceration  at- 
tacks the  various  lesions.  Then  while  these  degenerating  secondary 
lesions  are  appearing,  ulcerating,  and  cicatrizing,  and  old  ones  are  being 
replaced  by  new  lesions,  gummatous  infiltration,  of  the  mouth,  eye, 
subcutaneous  tissues,  bones,  and  joints,  and  the  cerebrospinal  system,  may 
develop  more  or  less  extensively.  Thus  we  see  men  covered  with  sec- 
ondary lesions  in  whom  tertiary  lesions  have  appeared  precociously, 
while  at  the  same  time  the  health  is  at  a  very  low  ebb,  and  there  may 
be  present  aphasia,  hemiplegia,  coma,  and  other  nervous  disturbances. 
Such,  briefly,  is  precocious  malignant  syphilis.  In  these  cases,  as  a  rule, 
want  of  treatment  or  imperfect  treatment  and  impaired  resistance  to 
the  virus,  are  the  underlying  cause  of  the  serious  course  of  the  disease. 


CHAPTER  XXY. 

COMPLICATIONS  AND  GENERAL  CONSIDERATION  OF 

SYPHILIS. 

Malignant  Syphilis. — Malignant  syphilis  is,  undoubtedly,  a  rare 
and  peculiar  form  of  the  infection.  Its  chief  characteristic  is  that 
it  is  essentially  a  secondary  condition  and  is  in  no  way  associated  with 
tertiary  syphilis.  Patients  thus  afflicted  show  evidence  of  profound 
systemic  poisoning  in  the  high  fever,  loss  of  flesh,  abject  marasmus, 
insomnia,  and  pains  in  various  parts  of  the  body.  There  also  may  be 
present  such  grave  symptoms  as  aphasia,  epilepsy,  coma,  and  paralyses. 
In  these  cases  the  nervous  affections  are  not  due  to  gummatous  deposit, 
but  rather  to  the  round-cell  infiltration  around  the  vessels,  chiefly  of 
the  membranes  of  the  brain.  The  cutaneous  lesions  are  at  first  erythe- 
matous and  papular,  with  the  general  disposition,  arrangement,  multi- 
plicity, etc.,  peculiar  to  the  secondary  period  and  without  the  localiza- 
tion and  comparative  sparseness  of  the  lesions  as  observed  in  precocious 
malignant  syphilis.  These  early  manifestations  very  soon  undergo 
degeneration  and  as  a  result  goodly  sized  ulcers,  rupia,  large  ulcerated 
plaques,  and  even  gangrenous  surfaces  are  produced.  None  of  these 
lesions,,  except  the  rupia,  resemble  in  their  course  tertiary  syphilitic 
ulcers  with  their  peculiar  mode  of  increase  and  with  their  occasional 
tendency  to  become  serpiginous.  Malignant  syphilis  usually  begins 
early  in  the  secondary  period,  and  very  uncommonly  later  than  the  end 
of  the  first  year  of  infection.  This  form  of  syphilis  is  very  rare  indeed, 
and  in  it  a  fatal  issue  is  often  observed.  Its  course  may  be  protracted, 
so  that  a  year  may  elapse  before  death  occurs  or  a  cure  is  effected. 
Malignant  syphilis  is  due  to  the  lack  of  resistance  on  the  part  of  the 
individual  to  the  severity  of  the  infection.  It  seems  that  the  poison 
meets  in  the  tissues  of  the  person  attacked  such  a  condition  of  recep- 
tivity that  it  is  generated  in  large  quantity  and  with  a  peculiar  virulence 
which  affects  the  whole  organism. 

In  some  cases  there  is  evidence  of  impaired  nutrition  in  persons 
thus  attacked,  but  it  is  sometimes  surprising  to  observe  malignant 
syphilis  in  well-built,  robust  subjects  of  good  habits.  It  seems  that 
in  spite  of  the  vigor  of  their  health  these  patients  lack  that  something 
which  constitutes  what  we  term  partial  immunity  to  the  syphilitic  virus. 
In  short,  their  tissues  present  fertile  culture-grounds  for  the  exuberant 

474 


ALCOHOLISM.  475 

growth  of  the  syphilitic  infection  and  the  poison  is  produced  in  large 
quantities,  while  the  cellular  elements  are  much  more  sparsely  pro- 
liferated. 

Tertiary  Syphilis. — The  persistence  of  the  syphilitic  infection 
beyond  the  secondary  period  results  in  the  production  of  a  certain 
morbid  state,  the  evolution  of  which  is  slow,  uncertain,  and  often  insid- 
ious, and  the  lesions  of  which  are  deeply  seated  in  the  subdermal  con- 
nective tissue,  mucous  membranes,  and  other  structures,  and  which  is 
called  tertiary  syphilis.  By  far  the  most  potent  cause  of  tertiary  syph- 
ilis is  absence  or  insufficiency  of  treatment  in  the  secondary  stage.  But 
in  addition  to  this  cause  there  are  others  which  result  from  lowered 
nutrition  and  weak  resistance  on  the  part  of  the  tissues.  Then,  again, 
certain  diseased  conditions,  may  act  as  secondary  factors  in  the  develop- 
ment of  this  late  and  erratic  stage  of  syphilis. 

Tuberculosis  and  Syphilis. — One  of  the  most  formidable  compli- 
cations of  syphilis  is  tuberculosis,  and  it  is  only  too  clearly  proved  that 
tissues  attacked  by  syphilis  become  perfect  hot-beds  for  the  fructifica- 
tion of  the  tubercle  bacillus.  This  destructive  and  deadly  symbiosis 
is  seen  in  the  secondary  and  in  the  tertiary  periods.  In  early  secondary 
syphilis,  even  when  well  treated  and  in  seemingly  healthy  subjects,  bron- 
chitis or  pneumonia  may  develop,  and  thereupon  acute  miliary  tubercu- 
losis may  supervene  and  carry  off  the  patient.  Then,  again,  when 
syphilis  runs  a  severe  course,  in  some  truly  malignant  cases,  tubercu- 
losis supervenes  and  quickly  kills  the  patient.  We  also  sometimes  see 
men  and  women  who  are  being  properly  treated  and  who  toward  the 
end  of  the  first  year  of  infection  begin  to  lose  weight  and  strength,  and 
are  attacked  by  pulmonary  symptoms.  Some  of  these  cases  are  bene- 
fited and  cured  by  change  of  climate  and  treatment,  but  many  are 
promptly  carried  off  by  this  virulent  tuberculous  complication.  Gum- 
matous infiltrations  of  any  or  all  of  the  viscera  are  liable  to  be  attacked 
by  tuberculosis,  and  syphilitic  sarcocele  is  not  infrequently  the  seat  of 
this  secondary  invasion.  When  considering  the  factors  of  gravity  in 
syphilis,  we  unfortunately  must  accord  to  tuberculous  infection  a  promi- 
nent place. 

Alcoholism. — Chronic  alcoholism  is  a  powerful  factor  in  inducing 
the  development  of  severe  and  extensive  lesions  of  the  skin  and  mucous 
membranes,  of  cerebral  disorders,  of  a  debilitated  condition  of  health, 
and  causes  the  disease  to  run  into  its  tertiary  stage.  It  is  then  very 
chronic  and  visceral  lesions  are  of  frequent  occurrence,  and  deeply 
seated  infiltrations  of  the  skin  and  mucous  membranes  develop,  which 
show  a  marked  tendency  to  soften  and  form  abscesses  and  ulcers  of 
great  persistency.  Alcoholism  in  the  lower  classes  is,  next  in  order  to 
the  absence  of  treatment,  the  most  frequent  cause  of  tertiary  syphilis. 


476  COMPLICATIONS  OF  SYPHILIS. 

When  arterial  or  visceral  degeneration  has  not  been  produced  and  with 
the  cessation  of  the  alcoholic  habit  much  encouragement  may  be  given 
to  such  patients  as  to  their  ultimate  cure,  provided  they  will  abstain 
from  alcohol  and  systematically  follow  the  treatment. 

Malaria. — In  malarial  subjects  the  course  of  the  disease  is  frequently 
severe,  the  condition  of  ill  health  is  well  marked,  neuralgias  are  very 
frequent,  and  the  specific  lesions  are  copious  and  extensively  distributed. 

Albuminuria. — Bright' s  disease  is  a  factor  of  much  gravity  in 
patients  infected  with  syphilis,  and  in  many  cases  its  course  is  very 
severe.  Then  again,  we  sometimes  see  men  and  women  who  have  ad- 
vanced kidney  degeneration  in  whom  syphilis  runs  a  surprisingly  mild 
course.  Ursemic  subjects  who  contract  syphilis  are  very  commonly 
profoundly  influenced  by  the  infective  process.  Their  lesions  are  ex- 
tensive and  show  a  tendency  to  ulceration,  and  the  general  depression 
of  health  is  very  marked. 

Diabetes. — When  in  the  course  of  syphilis  specific  brain  lesions 
lead  to  glycosuria  or  diabetes  insipidus,  these  grave  constitutional  con- 
ditions become  factors  in  the  production  of  a  general  breakdown  of 
the  system.  The  various  morbid  blood-states,  such  as  scurvy,  the  hem- 
orrhagic diathesis,  and  hemoglobinuria,  are  serious  complications  of 
syphilitic  infection,  and  in  patients  suffering  from  them  it  is  common 
to  observe  a  severe  course  of  the  disease.  Influenza  is  frequently  seen 
to  be  the  cause  of  great  systemic  depression,  and  it  may  become  a  factor 
of  much  gravity  in  syphilitic  patients,  in  some  of  whom  severe  pul- 
monary affections  occur. 

Rheumatism  and  Gout. — Rheumatism  and  gout  are  not  uncommon 
complications  of  serious  import  in  syphilitic  patients,  in  some  of  whom 
the  specific  lesions  are  materially  modified  by  this  harmful  symbiosis. 
And  in  some  cases  syphilis  seems  to  be  a  causative  factor  in  the  inten- 
sification and  prolongation  of  these  chronic  disorders. 

Acute  Infectious  Processes. — The  debility  following  various  infec- 
tive processes,  such  as  typhoid  fever,  diphtheria,  erysipelas,  and  the 
exanthemata  sometimes  renders  the  course  of  syphilis  severe  for  a  long 
or  short  period.  I  have,  however,  in  some  cases,  been  astonished  at 
the  extreme  mildness  of  secondary  syphilis  in  patients  who  had  a  short 
time  before  infection  recovered  from  erysipelas,  typhoid  fever,  or  diph- 
theria. 

Syphilis  in  Old  Age. — When  it  is  remembered  that  syphilis  expends 
its  morbid  action  largely  and  extensively  upon  the  bloodvessels,  the 
fact  strikes  one  that  in  old  persons  the  severity  of  the  attack  is  very 
much  influenced  by  the  condition  of  the  vascular  system.  Upon  the 
integrity  of  the  patient's  bloodvessels  hinges  in  a  large  degree  the 
varying  severity  of  syphilis.     In  old  persons  arteriosclerosis  is  com- 


SYPHILIS  IN  OLD  AGE.  477 

mon,  and  may  involve  more  or  less  of  the  circulatory  apparatus. 
Instances  of  this  involvement  combined  with  syphilis  are  not  at  all 
uncommon.  Besides  vessel-changes,  visceral  lesions,  general  debility,  an 
unstable  condition  of  the  tissues,  and  the  systemic  morbid  effects  pro- 
duced by  vicious  habits  and  indulgences,  are  undoubtedly  factors 
of  gravity  in  syphilis  in  advanced  life.  A  review  of  my  clinical 
experience  has  convinced  me  that  in  many  elderly  persons  of  vigorous 
physique  and  good  habits  syphilis  runs  a  comparatively  mild  course ; 
in  less  vigorous  persons  it  is  more  severe  ;  and  that  in  poorly  nourished, 
weakly,  and  underweight  individuals,  in  the  nervous,  excitable,  neuro- 
pathic, and  over-studious  (brain-workers  from  all  classes)  it  is  often 
severe  and  even  disastrous  in  its  effects. 

Early  and  efficient  treatment,  however,  is  most  essential,  and  by  it 
the  course  of  the  disease  in  the  aged  may  be  much  modified,  may  be 
rendered  mild,  and  in  many  cases  a  cure  may  result. 

Many  peculiarities  in  the  course  of  many  lesions  are  observed  in  aged 
syphilitics.  In  general  the  first  period  of  incubation  of  the  chancre  is 
quite  long.  The  initial  lesion  is  not  usually  exuberantly  large  and  indu- 
rated, but  more  commonly  slight  in  character,  parchment-like  in  thick- 
ness, with  a  tendency  to  superficial  necrosis  and  sloughing.  In  some 
cases  gangrene  and  phagedena  are  observed.  The  inguinal  adenopathies 
usually  appear  and  develop  slowly,  and  the  swollen  ganglia  are  rarely,  if 
ever,  very  large  and  nodular.  The  second  period  of  incubation  is  also 
usually  quite  prolonged,  so  that  two,  two  and  a  half,  and  even  three 
months  or  longer  may  elapse  between  the  appearance  of  the  chancre  and 
the  onset  of  general  manifestations.  As  Quinquaud  says,  "  syphilis 
acquired  after  sixty  years  of  age  is  a  drama,  the  successive  stages  of 
which  are  slower  in  their  evolution  than  those  of  syphilis  acquired  in 
early  life." 

Secondary  lesions  of  the  skin  and  mucous  membrane  do  not  present 
that  amount  of  hyperemia  and  exuberance  which  may  be  seen  in  the 
same  affections  in  early  life.  The  skin  lesions  may  be  generally  distrib- 
uted, and  perhaps  more  or  less  confluent,  but  they  always  show  more  or 
less  evidence  of  senectitude.  This  is  especially  well  shown  in  the  eryth- 
ematous and  papular  syphilides.  These  lesions  show  a  marked  tendency 
to  remain  in  an  indolent  condition,  and  are  frequently  very  rebellious  to 
treatment.  They  sometimes  show  an  exasperating  tendency  to  relapse 
even  when  a  vigorous  treatment  is  being  followed. 

It  is  not  uncommon  to  see  secondary  and  tertiary  skin  lesions  com- 
mingled. Thus,  roseola,  papules,  and  gummatous  nodules,  the  latter 
showing  a  tendency  to  break  down  and  suppurate,  may  not  uncommonly 
be  seen  scattered  over  the  integument  of  elderly  persons. 

Malignant  precocious  lesions  of  the  skin,  bones,  and  mucous  mem- 


478  COMPLICATIONS  OF  SYPHILIS. 

branes  are  not  at  all  uncommon,  some  of  which  show  a  tendency  to  gan* 
grene  and  necrosis. 

Quite  early  in  the  secondary  stage  nervous  and  psychical  troubles 
with  paralysis  are  not  uncommon,  and  headache,  neuralgic  and  rheuma- 
toid pains  may  also  be  complained  of.  Cerebral  accidents,  with  symp- 
toms resembling  typhoid  fever,  may  also  be  observed. 

Gummatous  infiltration  into  the  ganglia  not  infrequently  undergoes 
degeneration  in  old  persons. 

Another  marked  feature  of  syphilis  in  the  aged  is  the  multiplicity  of 
the  tissues  and  organs  attacked  at  the  same  time,  such  as  the  skin,, 
mucous  membranes,  bone,  viscera,  and  the  cerebrospinal  axis. 

It  has  been  observed  that  after  seventy  years  of  age  the  pharynx  is 
rarely  attacked,  that  the  brain  and  scalp  are  usually  unaffected,  and  that 
the  gums  are  more  free  from  the  effect  of  mercurials  than  in  earlier 
years. 

All  these  significant  facts  concerning  syphilis  contracted  late  in  life 
should  be  clearly  borne  in  mind,  and  a  more  than  usual  watchful  care 
should  be  exercised  over  these  venerable  patients.  It  is  well  to  empha- 
size the  fact,  however,  that  in  some  old  persons  of  both  sexes  syphilis 
runs  a  tolerably  mild  course,  and  is  measurably  amenable  to  treatment. 
Consequently,  it  is  not  well  always  to  give  a  gloomy  prognosis  in  these 
cases. 

On  account  of  its  rarity,  the  case  reported  by  Cohn  is  interesting. 
It  was  that  of  a  virile  man  who  at  eighty  years  of  age  contracted 
syphilis,  which,  though  severe,  was  cured  by  specific  treatment. 

Cancer. — Syphilis  is  in  no  sense  of  the  term  an  etiological  factor  in 
the  development  of  cancer,  but  in  some  cases  it  acts  as  the  forerunner 
and  the  predisposing  cause  of  the  latter  disease  by  means  of  the  chronic 
irritative  processes  which  it  establishes.  As  a  rule,  cancer  consecutive 
to  syphilitic  processes  develops  in  the  mouth,  particularly  on  the  tongue 
and  near  its  mucocutaneous  junctions.  It  may  also  appear  on  the  skin 
proper  following  certain  chronic  inflammatory  syphilitic  processes.  As 
a  result,  a  hybrid  disease  is  produced,  usually  in  the  tertiary,  and  excep- 
tionally in  the  late  secondary,  period  of  syphilis. 

IMMUNITY  TO  SYPHILIS. 

While  in  general  it  may  be  said  that  syphilis  may  attack  any  indi- 
vidual, there  are  some  who  possess  a  varying  degree  of  immunity  to  this 
infection,  Asa  rule,  one  attack  of  acquired  syphilis  confers  immunity 
to  subsequent  infection. 

Persons  who  in  early  life  have  been  the  subjects  of  inherited  syphilis 
in  the  majority  of  cases  are  not  susceptible  to  acquired  infection.  This 
has  been  called  Profeta's  law. 


S  YPHIL  OP  11  OBI  A.  479 

As  a  rule,  a  healthy  mother  who  carries  an  embryo  rendered  syphil- 
itic by  its  father  is  herself  not  liable  to  acquire  syphilis.  This  state- 
ment is  called  Colles's  law. 

SYPHILOPHOBIA. 

Syphilophobia  is  sometimes  included  among  the  manifestations  of 
syphilis,  but  I  do  not  believe  that  it  is  directly  due  to  this  disease.  It 
is  quite  as  often  met  with  in  patients  affected  only  with  gleet,  prostator- 
rhoea,  or  who  have  nothing  at  all  the  matter  with  them  except  their 
own  disordered  imagination.  Moreover,  in  truly  syphilitic  cases  the 
fear  of  syphilis  often  increases  in  proportion  as  the  specific  symptoms 
disappear. 

Syphilitic  patients  will  sometimes  state  that  they  have  resolved  to 
give  up  their  business  and  devote  their  time  to  the  cure  of  their  dis- 
ease. Such  a  course  should  always  be  discouraged,  since  it  favors 
mental  depression,  interferes  with  the  general  health,  and  thus  retards 
the  effect  of  remedies,  and  may  lead  to  confirmed  hypochondria  or 
syphilophobia. 

Fournier  has  recently  laid  stress  on  the  occurrence  of  suicide  in 
syphilitics.     He  divides  these  cases  into  four  classes,  as  follows : 

1.  Cases  in  which  the  suicide  is  the  result  of  a  mental  trouble  arising 
directly  from  the  syphilis ;  2.  Cases  in  which  suicide  is  the  result  of 
despair  of  the  patient,  who  has  suffered  from  external  syphilitic  symp- 
toms which  are  of  a  serious  nature,  or  so  considered  by  him  ;  3.  Cases 
associated  with  the  original  announcement  to  the  patient  that  he  is 
syphilitic ;  4.  Cases  depending  on  the  social  position,  where  syphilis  has 
definite  relations  with  marriage  or  social  standing. 

The  first  group  includes  those  cases,  the  most  numerous  of  all,  where 
a  mental  trouble  is  directly  the  result  of  the  syphilis,  that  is  to  say, 
syphilitic  encephalitis,  gumma  of  the  brain,  general  paralysis  of  the 
insane,  referable  to  the  infection.  In  certain  forms  of  syphilitic  encepha- 
litis suicide  is  a  symptom,  and  at  a  very  early  period  of  the  disease.  It 
appears  so  suddenly  that  it  overpowers  the  patient,  who  has  been  in  a 
seemingly  healthy  condition.  It  may  also  develop  after  many  years, 
and  in  cases  of  hereditary  syphilis. 

In  the  second  class,  where  shame  at  contracting  a  venereal  disease, 
or  a  disfiguring  ulceration  of  the  face,  is  present  Fournier  thinks  that 
physicians  should  appreciate  the  special  mental  and  moral  attitude  of 
their  patients,  so  as  not  to  be  taken  unaware  by  suicide  from  this  cause. 

In  the  third  class,  where  suicide  follows  the  first  notification  of  syphi- 
lis, the  fault  lies  in  the  abrupt,  tactless  announcement  on  the  part  of  the 
physician  to  patients  who  are  syphilophobiaos. 

In  America  suicide  in  the  third  form  of  cases  is  most  rare,  but  it  is 


480  COMPLICATIONS  OF  SYPHILIS. 

well  as  advised  by  Fournier,  particularly  in  nervous  and  impressionable 
individuals,  to  take  time  in  making  a  positive  diagnosis,  and  not  to  let  it 
come  to  the  patient  like  a  thunderclap. 

IGNORED   SYPHILIS. 

It  is  not  uncommon  in  clinics  and  hospitals,  and  also,  though 
less  frequently,  in  private  practice,  to  see  cases  of  tertiary  syphilis  in 
which  no  history  of  primary  or  secondary  lesions  can  be  obtained  even 
after  rigorous  cross-questioning.  These  cases  are  classed  under  the 
heading  of  "  ignored  syphilis  "  and  under  that  of  "  syphilis  occulta."  As 
an  example  of  the  frequency  of  occurrence  of  ignored  syphilis  it  may  be 
mentioned  that  in  a  five  months'  service  at  the  St.  Louis  Hospital,  Four- 
nier saw  28  cases,  and  that  Lassar  in  200  cases  of  late  syphilis  saw 
60  (about  30  per  cent.)  in  which  no  evidence  of  the  early  stages  could 
be  obtained. 

Ignored  syphilis  is  observed  in  women  much  more  frequently  than  in 
men,  and  in  ignorant  and  careless  persons  in  the  lower  walks  of  life  it  is 
far  from  uncommon.  Many  women  have  but  the  most  elementary  ideas 
regarding  syphilis,  while  men,  as  a  rule,  are  quite  well  informed  upon 
the  subject.  In  many  women  the  initial  lesion  is  extragenitally  seated, 
and  its  true  nature  and  that  of  its  sequelae  are  never  known  to  them. 
Then,  again,  by  many  women  the  genital  chancre  is  not  seen,  or  it  is  so 
insignificant  in  appearance  and  mild  in  character  that  its  gravity  is  not 
appreciated.  The  chancre  in  some  men  is  so  insignificant  and  short- 
lived that  it  is  looked  upon  as  a  chafe  or  as  herpes. 

Owing  to  their  mild  character  and  ephemeral  course  the  early  syphil- 
ides  in  some  cases  pass  unobserved  or  unappreciated.  It  is  very  common 
in  clinics  and  hospitals  to  call  a  patient's  attention  to  a  roseolous  or  a 
papular  syphilide  on  his  or  her  body,  of  which  he  or  she  had  no  knowl- 
edge or  suspicion. 

Then,  again,  in  many  cases  the  inguinal  adenopathies  may  pass  unob- 
served, or,  if  their  existence  is  known,  the  patient  is  ignorant  of  their 
import.  Mild  primary  and  secondary  syphilis  are  the  usual  unrecognized 
forerunners  of  tertiary  syphilis. 

Many  women  and  children  have  syphilis,  and  suffer  severely  from  it, 
yet  they  know  nothing  of  the  nature  of  their  disease.  It  often  happens, 
as  Fournier  aptly  says,  that  "  in  women  syphilis  is  the  more  likely  to  re- 
main ignored,  since  all  that  is  possible  is  done  to  hide  the  nature  of  the  dis- 
ease from  them.  The  husband  or  the  lover  entreats  the  surgeon  to  treat 
his  victim  without  revealing  to  her  the  cause  of  her  malady ;  and  amid 
this  'conspiracy  of  silence'  she  becomes  cured  of  her  syphilis  ignores." 

In  some  cases  for  various  reasons  patients  utterly  deny  having  had 
primary  or  secondary  syphilis. 


CHANGES  IN  THE  BLOOD  IN  SYPHILIS.  481 

Errors  in  diagnosis  on  the  part  of  physicians  not  infrequently  lead 
patients  to  think  that  they  never  had  syphilis. 

It  follows,  therefore,  that  we  shall  constantly  meet  with  cases  of  ter- 
tiary syphilis  in  which  the  lesions  or  symptoms  are  so  strikingly  pathogno- 
monic that  no  doubts  as  to  their  nature  can  be  entertained,  yet  in  which 
no  evidence  of  early  infection  is  obtainable. 

CHANGES   IN   THE   BLOOD   IN   SYPHILIS. 

As  a  result  of  the  infection  various  grades  of  anaemia  may  be  ob- 
served. In  exceptional  cases  a  condition  similar  to  pernicious  anaemia 
may  be  produced.  In  the  primary,  secondary,  and  tertiary  forms  the 
red-cells  and  the  haemoglobin  may  be  more  or  less  reduced  for  longer  or 
shorter  intervals.     In  some  cases  no  blood  abnormality  can  be  found. 

Leucocytosis  is  a  very  constant  condition  in  most  cases,  and  is  devel- 
oped in  various  degrees ;  in  some,  however,  it  is  absent.  Mercurial 
treatment  usually  results  in  the  suppression  of  the  leucocytosis  coin- 
cidently  with  the  involution  of  specific  lesions  and  the  improvement  in 
the  patient's  health. 

Lowenbach  and  Oppenheim  made  researches  into  the  condition  of 
the  blood  in  early  and  late  syphilis,  and  found  a  marked  reduction 
from  the  normal  in  the  quantities  of  both  iron  and  haemoglobin,  neither 
condition  being  influenced  by  therapeutic  measures. 

Justus'  Test  of  the  Blood  in  Syphilis. — An  extensive  series 
of  observations  with  especial  reference  to  their  diagnostic  value  has  been 
made  on  the  haemoglobin  of  the  blood  of  syphilitics  by  J.  Justus.  More 
than  500  cases  of  all  varieties  are  included,  treated  and  untreated.  He 
found  that  untreated  cases  of  syphilis  show  a  diminution  of  haemoglobin 
which  lasts  a  longer  or  shorter  time,  depending  on  the  severity  of  the 
disease.  A  gradual  increase  then  takes  place  as  the  signs  of  syphilis 
subside.  If  a  therapeutic  does  of  mercury  is  introduced  into  the  affected 
organism  by  injection  or  inunction,  a  relatively  sudden  decrease  of  the 
haemoglobin  standard  is  observed  (10  to  30  degrees  in  the  Gowers'  or 
Fleischls'  haemoglobinometer).  This  sinking  may  again  be  compensated 
for  in  the  course  of  a  few  days,  depending  on  the  severity  of  the  symp- 
toms and  the  general  condition  of  the  patient.  If  the  treatment  is  con- 
tinued, the  haemoglobin  may  reach  a  higher  point  than  before  the  former 
was  inaugurated,  and  the  point  when  no  further  decrease  takes  place 
marks  the  period  when  healing  of  the  specific  lesions  begins.  It  is  fur- 
ther claimed  that  the  changes  in  haemoglobin  standard  just  noted  are  only 
to  be  found  in  the  blood  of  florid  syphilitic  patients,  and  have  not  been 
observed  in  health  or  in  any  other  disease.  The  reaction  can  be  also 
found  when  invasion  of  distant  lymph-glands  takes  place  and  in  all 
varieties  of  the  disease.     It  disappears  when  the  syphilitic  lesions  disap- 

31 


482  COMPLICATIONS  OF  SYPHILIS. 

pear,  but  can  again  be  demonstrated  if  any  recurrence  takes  place.  In 
using  the  test  for  diagnostic  purposes  care  must  be  taken  to  employ  the 
proper  dose  of  mercury,  at  least  45  grains  of  the  officinal  blue  ointment 
for  adults,  by  inunction.  Administration  by  mouth  is  not  effective  be- 
cause of  the  slow  absorption.  Observations  should  be  made  the  morn- 
ing after  the  inunction.  Subcutaneous  injections  of  mercury  bichloride 
(0.05  gm.)  should  be  followed  by  observation  eight  to  nine  hours  later. 
The  author  prefers  the  Gower  hsernoglobinorneter  modified  by  Sahli.  A 
diminution  of  5  degrees  or  more  in  the  latter  instrument  indicates  the 
presence  of  a  florid  syphilis.  In  secondary  and  tertiary  syphilis  the 
same  result  obtains  provided  the  specific  lesions  have  not  undergone  in- 
volution. A  negative  result  is  not,  therefore,  diagnostic  of  the  absence 
of  the  disease  (at  some  previous  time).  The  author  finds,  from  a  study 
of  all  cases  where  the  test  was  properly  applied,  a  positive  result  in  from 
70  to  80  per  cent,  of  all  doubtful  cases. 

In  regard  to  Justus'  test  of  the  blood  in  syphilis  Ewing's  criti- 
cism is  worthy  of  attention.  He  says  :  "  Further  studies  are  required 
before  the  value  of  Justus'  test  can  be  shown,  but  on  general  grounds  it 
would  seem  that  the  test  would  prove  unreliable  in  many  cases  of  anaemia, 
when  the  globulicidal  action  of  mercury  might  dissolve  no  cells. 

THE  MICRO-ORGANISMS  AND  BACILLUS  OF  SYPHILIS. 

The  bacteriology  of  syphilis  is  as  yet  in  a  wholly  unsettled  state,  as 
is  shown  by  the  results  arrived  at  by  several  distinguished  investiga- 
tors. According  to  Max  Schiiller,  who  has  studied  syphilitic  tissues 
very  extensively,  certain  structures  which  have  much  in  common  with 
those  he  has  described  as  being  the  causative  agents  of  carcinoma  have 
been  found.  The  organisms  found  in  the  syphilitic  tissues  he  considers 
may,  like  those  of  carcinoma,  be  held  to  be  members  of  some  group  of 
hitherto  unknown  protozoa.  These  consist  mainly  of  two  forms  which 
may  easily  be  obtained  in  fresh  smears  from  primary  lesions.  The  first 
form,  which  the  author  names  "  large  capsules,"  when  well  preserved  usu- 
ally appear  as  somewhat  pyriform  or  three-cornered  bodies  of  brownish- 
yellow  color.  Their  contents  are  of  a  darker  shade,  while  the  shell  is  of 
a  glistening  yellowish  tinge.  Under  a  high  power  small  knob-like  eleva- 
tions are  distinctly  to  be  seen.  Nucleated  masses  are  also  to  be  seen 
which  apparently  are  the  extruded  protoplasmic  contents  of  the  capsule. 
The  second  form  consists  of  much  smaller  rounded  bodies  somewhat 
lighter  in  color,  having  a  double  contour,  and  which  exhibit  distinct  radial 
striations.  These  are  termed  by  the  author  "  young  organisms,"  as  in  his 
culture  experiments  they  appear  to  develop  partly  in  the  interior  of 
the  larger  capsules  and  partly  by  fission.  The  author's  investigations 
embraced  studies  of  smears  and  sections  from  chancres,  enlarged  glands, 


IMMUNITY  OF  ANIMALS  TO  SYPHILIS.  483 

condylomata,  gummata,  joint-tissues,  etc.,  taken  from  patients  in  the 
three  stages  of  the  disease  and  from  those  suffering-  from  hereditary 
syphilis.  In  all  of  these,  structures  similar  to  those  described,  and 
also  many  modified   forms,   were  discovered. 

On  the  other  hand,  Max  Joseph  and  Piorkowski  have  convinced 
themselves  that  a  specific  bacillus  has  been  found  by  them.  This  hith- 
erto undescribed  bacillus  was  isolated  from  the  spermatic  fluid.  The 
only  way  in  which  such  investigation  was  successful  was  by  cultivating 
this  fluid  upon  sterile  placenta  at  the  incubator  temperature  for  two  or 
three  days.  In  the  secondary  generation  the  bacilli  could  be  grown  upon 
the  ordinary  artificial  culture-media.  Upon  such,  however,  they  soon 
showed  degenerative  appearances,  and,  unless  retransplanted  upon  human 
media,  soon  died.  With  Loffler's  methylene-blue  they  stain  almost 
identically  to  the  diphtheria  bacillus  ;  in  size,  however,  they  correspond  to 
bacillus  subtilis.  They  stain  positive  with  Gram's  liquid.  They  are  not 
pathogenic  for  the  ordinary  laboratory  research  animals ;  they  are  non- 
motile,  coagulate  milk,  produce  an  abundant  sediment  in  bouillon,  and 
grow  in  a  white,  shining  layer  upon  potato.  They  produce  neither  gas 
nor  indol,  and  spore-formation  has  not  been  observed.  They  do  not 
liquefy  gelatin.  These  bacilli  have  never  been  cultivated  from  the  sper- 
matic fluid  of  normal  men  or  of  those  suffering  from  tertiary  syphilis. 
Fifteen  of  the  former  experiments  have  been  made  and  eleven  of  the 
latter.  On  the  other  hand,  this  bacillus  has  been  frequently  isolated  from 
mucous  patches  and  enlarged  inguinal  glands  of  secondary  syphilis.  The 
effect  of  the  administration  of  mercury  upon  the  presence  of  the  bacillus 
in  the  spermatic  fluid  is  varied.  In  some  cases  under  such  treatment  it 
soon  disappears,  while  in  others  it  remains  for  a  long  time.  The  authors 
think  that  the  facts  already  produced  warrant  the  assumption  that  this 
bacillus  is  the  causative  agent  in  the  production  of  syphilis.  Experi- 
ments on  animals  were  negative.  Attempts  were  made  to  infect  mice, 
guinea-pigs,  puppies,  and  swine,  but  no  apparent  influence  of  the  subcu- 
taneous and  intraperitoneal  injection  of  the  eultures  could  be  observed. 

THE    QUESTION  OF   THE  IMMUNITY  OF  ANIMALS  TO 

SYPHILIS. 

The  opinion  has  long  been  held  that  animals  are  immune  to  syphilitic 
infection. 

Martineau  about  fifteen  years  ago  claimed  that  he  had  communicated 
the  disease  to  pigs  and  monkeys.  Koch  so  utterly  demolished  Martineau' s 
conclusions,  and  made  such  ridicule  of  his  technical  methods,  that  his 
inoculation-experiments  went  for  naught. 

Rabetel  made  incisions  into  the  groin  of  a  perfectly  healthy  bitch,  and 
in  the  cellular  tissue  he  placed  portions  of  a  fresh,  hard  chancre,  and  then 


484  COMPLICATIONS  OF  SYPHILIS. 

closed  the  wound.  There  was  an  ephemeral  swelling  of  the  parts,  but  in 
a  few  days  nothing  abnormal  was  to  be  seen.  No  glandular  swelling 
occurred  in  a  period  of  many  months.  He  also  injected  1 50  grammes 
of  defibrinated  blood-serum  from  a  patient  with  active  syphilis  into  the 
jugular  vein  of  a  young  dog,  without  any  eifect  whatever.  These  ani- 
mals subsequently  procreated  healthy  offspring. 

Kobner  was  successful  in  inoculating  rabbits  with  chancroidal  pus,  but 
he  failed  to  infect  dogs  and  rabbits  by  means  of  inoculations  with  active 
syphilitic-bearing  vehicles. 

Horand  and  Cornevin  tried  very  assiduously  to  infect  the  pig  with 
syphilis,  but  they  reached  the  conclusion  that  the  tissues  of  this  animal 
are  refractory  to  this  disease. 

Cognard  claimed  that  he  had  inoculated  a  monkey  with  syphilis,  but 
his  colleagues  thought  that  he  had  simply  produced  septicaemia  in  that 
unfortunate  animal. 

Vittone  inoculated  without  success  the  fragments  of  six  chancres 
upon  rabbits,  guinea-pigs,  cats,  and  dogs. 

Neumann  inoculated  active  syphilitic  material  into  three  apes,  three 
rabbits,  a  horse,  a  hare,  a  white  rat,  a  martin,  and  a  cat.  Though  he 
made  fifty-four  inoculations  in  all,  his  experiments  were  uniformly  unsuc- 
cessful. 

Haensell  claims  that  he  injected  syphilitic  products  into  the  anterior 
chamber  of  the  eyes  of  rabbits,  and  produced  iritis  and  little  nodules 
which  appeared  from  twenty-five  days  to  one  and  three  months  after  the 
inoculation.  These  nodules  were  looked  upon  as  gummata,  and  the  con- 
clusion of  the  experimenter  was  that  he  had  produced  syphilis ;  but 
there  is  no  evidence  offered  of  the  existence  of  a  general  infection. 

Lassar,  1904,  claims  that  he  successfully  inoculated  a  chimpanzee 
with  syphilitic  virus.  The  animal  was  a  vigorous  male  four  to  five  years 
old.  The  patient  from  whom  the  virus  was  obtained  was  a  young  man, 
who  had  contracted  the  disease  through  the  use  of  infected  tattooing; 
needles,  and  the  material  used  was  taken  from  the  primary  lesion  on  his 
arm.  He  also  undertook  the  care  of  the  animal  after  the  infection,  a 
matter  of  some  importance,  since,  if  the  experiment  proved  successful, 
any  injury  inflicted  by  the  chimpanzee  on  his  healthy  attendants  would 
be  likely  to  have  serious  consequences.  Bits  of  tissue  and  secretion  from 
the  patient's  chancre  were  placed  in  pockets  and  punctures  made  under 
the  skin  of  the  forehead,  the  ears,  and  in  the  mucous  membrane  of  the 
mouth.  These  various  spots  healed  promptly  and  without  reaction,  and 
only  two  showed  any  later  change.  These  were  above  the  eyebrows,  and 
on  the  fourteenth  day  began  to  show  induration,  which  subsequently 
assumed  the  typical  appearance  of  a  hard  chancre.  Still  more  important 
as  evidence  of  infection  is  the  fact  that  other  lesions  developed  in  the 


REINFECTION   WITH  SYPHILIS.  485 

palms  of  the  hands,  on  the  soles  of  the  feet,  and  about  the  anus.  Similar 
eruptions  appeared  on  the  arms,  the  forehead,  and  on  the  scalp,  which 
gradually  lost  its  hair.  Microscopical  sections  also  seemed  to  demonstrate 
that  the  formerly,  accepted  dictum  that  syphilis  is  non-transmissible  to 
animals  is  erroneous,  and  that  the  anthropoid  apes  are  susceptible  to  the 
disease. 

Similar  results  were  obtained  by  Roux  and  Metchnikoff  by  experi- 
mental inoculation  on  anthropoid  apes.  Many  other  cases  of  experimental 
inoculation  with  the  products  of  syphilis  upon  pigs,  rabbits,  and  guinea- 
pigs  have  recently  been  reported  as  successful,  upon  which  a  verdict  of 
not  proved  is  all  that  can  be  said. 

REINFECTION  WITH  SYPHILIS. 

As  a  general  rule,  syphilis,  like  small-pox,  scarlet  fever,  measles,  etc., 
attacks  the  individual  but  once  in  his  lifetime,  but  a  sufficient  number  of 
well-attested  cases  have  been  published  to  warrant  the  statement  that  in 
certain  rare  instances  syphilis  does  attack  the  individual  twice  in  his  life- 
time. There  have  been  published  up  to  date  about  one  hundred  and 
sixty  cases  of  syphilitic  reinfection,  and  it  is  safe  to  say,  allowing  much 
latitude,  that  not  thirty  of  the  whole  number  are  authentic  instances. 

The  great  source  of  error  in  this  subject  is  to  be  attributed  to  the 
relapsing  indurations,  which  thoroughly  convince  many  men  that  they 
have  a  second  hard  chancre  before  them.  As  the  knowledge  of  these 
lesions  becomes  more  clear  and  extended  there  will  be  fewer  reported 
cases  of  second  infection  with  syphilis. 

When  we  carefully  review  the  whole  subject  we  may  admit  that 
genuine  second  attacks  of  syphilis  occur,  but  that  they  are  very  rare. 
All  suspected  and  putative  cases  should  be  approached  with  caution  and 
reserve,  rather  than  with  a  sanguine  and  credulous  spirit.  We  need 
much  further  light  on  this  important  subject,  and  scientific  evidence  can 
only  be  obtained  by  a  rigid  examination  and  study  of  each  case.  Before 
a  given  case  shall  be  accepted  as  true  and  beyond  controversy  the  fol- 
lowing facts  must  be  established  as  clearly  as  possible  :  In  the  first 
attack,  the  existence  of  a  true  hard  chancre  followed  by  characteristic 
adenopathies  and  a  clear  history  of  the  secondary  stage  and  its  lesions, 
and  perhaps  of  a  tertiary  stage.  Then  a  sufficiently  long  period  of 
time  should  elapse  in  order  to  show  that  the  diathesis  has  become 
extinct.  Many  cases  have  been  reported  in  which  one,  two,  or  three 
years  only  have  elapsed  between  the  two  so-called  separate  attacks  of 
syphilis.  Such  cases  are  without  doubt  apocryphal.  In  the  light  of 
the  cases  already  published  it  is  not  too  much  to  say  that  no  case  is 
worthy  of  consideration  in  which  the  interval  between  the  cure  or  ap- 
parent cessation  of  the  first  attack  and  the  onset  of  the  second  one  is  at 


486  COMPLICATIONS  OF  SYPHILIS. 

least  not  under  five  or  six  years.     Very  long  intervals  will  inspire  one 
with  moderate  credulity. 

The  further  requirements  are  that  the  history  and  characteristics  of 
the  second  chancre  shall  be  satisfactorily  made  clear,  and  the  involve- 
ment of  the  ganglia  established  beyond  a  doubt.  Then  a  clear  clinical 
picture  of  the  period  of  general  manifestations  must  be  given  before  we 
accept  the  case  as  one  of  second  infection  with  syphilis.  If  these  re- 
quirements are  fulfilled,  it  is  safe  to  say  that  in  the  future  we  shall  not 
be  favored,  as  we  have  of  late  about  once  in  two  or  three  months,  with 
a  new  case  of  syphilitic  reinfection. 

It  is  stated  by  a  number  of  writers  that  second  attacks  of  syphilis 
run  a  very  mild  course.  Since  this  statement  is  largely  based  upon  the 
features  oifered  by  apocryphal  cases,  it  is  not  worthy  of  consideration. 
In  my  five  cases  the  second  attack  was  very  severe,  and  in  two  instances 
it  ended  promptly  in  death.  It  is  unwise,  however,  to  draw  conclusions 
from  a  few  cases  ;  therefore  it  is  well  to  wait  for  future  observations  as 
to  the  intensity  of  the  course  of  cases  of  second  infection  with  syphilis. 

In  Plate  XXVII.  is  admirably  depicted  a  case  of  second  infection 
with  syphilis  which  was  under  my  observation  in  the  two  attacks  of  this 
disease.  The  first  infection  with  syphilis  occurred  when  the  woman  was 
twenty-seven  years  of  age.  She  had  the  primary  or  initial  lesion,  which 
was  followed  by  marked  indurating  oedema  of  the  labia  minora  and  majora, 
together  with  typical  inguinal  adenopathies.  She  further  had  a  general- 
ized papular  syphilide  and  mucous  patches,  and  suffered  from  nocturnal 
pains  and  rheumatism.  Later,  a  characteristic  serpiginous  syphilide  ap- 
peared on  the  arms  and  forearms  and  neck.  Syphilitic  muscular  contrac- 
tion of  the  right  biceps  brachialis  was  severe  and  persistent.  In  Plate 
XXVII.  is  well  shown  the  scars  left  by  the  serpiginous  syphilide,  and 
typical  scars  were  also  seated  on  the  right  side  of  the  neck  and  on  the 
right  arm.  Eleven  years  after  the  onset  of  the  first  attack  of  syphilis, 
the  second  infection  occurred.  For  some  time  I  was  unable  to  discover 
the  initial  lesion  of  this  attack,  but  later  I  found  it  very  clearly.  From 
my  notes  I  quote  the  facts  as  to  the  second  infection  with  syphilis :  I  found 
this  woman  again  in  my  wards,  presenting  a  pitiable  appearance.  She 
was  thin,  emaciated,  and  weak,  and  showed  a  low  power  of  assimilation. 
She  had  become  broken  down  by  reason  of  irregularities  of  life  and  pri- 
vation. Over  her  whole  face  and  neck  was  a  profuse,  small,  miliary, 
papular  syphilide  scattered  in  indiscrete  form.  Throughout  the  scalp, 
papules  and  small  pustules  were  abundant.  In  the  centre  of  the  forehead 
a  well-marked  incrusted  rupial  ulcer  was  prominent.  Over  the  body  the 
miliary  syphilide  was  very  copious  and  conspicuous,  existing  in  its  typical 
corymbiform  arrangement,  and  also  as  a  generalized  scattered  eruption. 
Nothing  could  be  more  positively  diagnostic,  for  between  the  papules, 


PLATE  XXVII, 


AUTHOR'S  CASE  OF  SECOND   INFECTION   WITH   SYPHILIS. 


REINFECTION   WITH  SYPHILIS.  487 

fading,  slight  patches  of  roseola  could  be  distinctly  seen.  Over  the  arms 
and  forearms  the  miliary  syphilide  was  copiously  scattered,  and  over  the 
thin,  delicate  cicatrices  of  the  serpiginous  syphilide  of  the  first  infection 
these  papules  were  placed  in  great  numbers.  On  the  left  arm  the  sequelae 
of  the  hospital  vaccination  had  developed  into  an  incrusted  rupial  ulcer. 
The  general  appearance  of  the  patient  and  of  her  lesions  is  well  shown  in 
Plate  XXVII.  Over  the  whole  body  the  ganglia  were  markedly  en- 
larged. She  also  suffered  from  mucous  patches  of  the  tongue  and  mouth, 
and  showed  evidences  of  alopecia.  She  suffered  severely  with  pains  in 
the  larger  upper  joints  and  in  the  knees  and  feet  by  day  and  worse  at 
night.  As  a  result  she  was  confined  to  bed,  and  her  cure  was  no  doubt 
retarded  in  consequence  of  want  of  exercise,  fresh  air,  and  sunlight.  She 
was  treated  by  mercurial  inunctions  and,  by  reason  of  the  existence  of 
the  fibrous  tissue  lesions,  iodide  of  potassium  was  at  times  administered. 
As  a  result  the  active  lesions  were  cured,  her  general  condition  was  much 
improved,  and  she  suffered  from  no  pains. 

I  have  had  under  my  care  and  observation  four  other  cases  of  rein- 
fection with  constitutional  syphilis. 

As  I  have  said  before,  the  scrutiny  of  cases  claimed  to  be  instances 
of  second  infections  with  syphilis  cannot  be  too  rigid,  and  in  these  days, 
\^hen  so  many  putative  cases  of  reinfection  are  being  published,  it  is 
necessary  to  examine  them  carefully  before  accepting  them. 


CHAPTEK    XXVI. 

PATHOLOGY    OF    SYPHILITIC    INFECTION    AND    OF    THE 
SYPHILITIC    PROCESSES. 

Considered  structurally,  syphilitic  inflammation  is  in  many  respects 
similar  to  tubercular  inflammation,  and  the  lesions  of  syphilis  viewed  as 
a  whole  resemble  tuberculosis  morphologically  more  closely  than  any  of 
the  other  classes  of  inflammation.  In  all  probability,  syphilis  is  due 
to  the  presence  in  the  body  of  some  form  of  bacterium  which  yields 
a  specific  toxin  which  is  a  largely  instrumental  factor  in  producing 
some  the  syphilitic  manifestations. 

With  the  exception  of  the  formation  of  gummata,  the  characteristic 
feature  of  the  secondary  and  tertiary  periods  is  an  early  and  persis- 
tent involvement  of  the  bloodvessels  throughout  the  whole  course  of  the 
disease.  In  addition  to  these  two  characteristic  lesions  of  syphilitic 
inflammation,  a  third  morbid  condition  may  occur,  which  consists  in 
a  tendency  to  the  production  of  new  connective  tissue,  especially  in 
the  central  nervous  system  in  the  late  stages  of  the  disease,  perhaps 
years  after  the  invasion  of  the  primary  sore.  This  chronic  production 
of  connective  tissue  is  a  slow,  persistent,  gradually  progressive  process, 
and  many  of  the  scleroses  of  the  nervous  system — such  as  tabes  dorsalis, 
for  instance — may  be  ascribed  to  it.  Whether  this  late  and  chronic 
production  of  connective  tissue  in  the  nervous  system  is  due  to  some 
inherent  property  of  the  syphilitic  virus,  stimulating  the  connective- 
tissue  cells  directly,  or  whether  the  new  tissue  grows  as  a  result  of  the 
tendency  of  syphilis  to  damage  the  bloodvessels,  cannot  be  definitely 
determined. 

In  addition  to  these  three  more  or  less  distinctive  traits  of  syphilitic 
inflammation — viz.,  the  gummy  tumor,  the  persistent  involvement  of 
the  bloodvessels,  and  the  late  and  gradual  production  of  new  tissue  in 
the  central  nervous  system — the  general  lesion  of  the  disease  is  the 
occurrence  of  more  or  less  circumscribed  tissue,  which  consists  of  small 
round  cells,  or  of  these  mingled  with  larger  polyhedral  cells,  or  occa- 
sionally giant  cells.  This  is  the  tissue  which  is  found  in  the  earlier 
stages  of  the  disease  in  the  initial  sores,  papules,  tubercles,  and  con- 
dylomata. 

This  newly  formed  richly  cellular  tissue,  occupying  large  or  small 
areas,  may  be  circumscribed  or  spread  out  diffusely,  especially  in  the 
mucous  membranes.     These  foci,  as  a  rule,  contain  few  bloodvessels, 

488 


PATHOLOGY  OF  SYPHILITIC  INFECTION,   ETC. 


489 


and  tend  to  undergo  coagulation-necrosis,  and  to  disintegrate  at  their 
centres.  Finally,  they  may  be  converted  into  cicatricial  tissue.  The 
bloodvessels  near  these  inflammatory  foci  frequently  have  swollen  or 
proliferating  endothelium   and  infiltrated   walls.     Later   on  the  blood- 


Fig.  119. 


Showing  the  chancre  (at  the  right  upper  part)  and  small  vessels  with  the  coat-sleeve  arrangement 
of  the  cell-infiltration  in  the  deep  connective  tissue  under  and  beyond  the  chancre.  (Vessels 
represented  by  red  dots  in  Fig.  119.) 

vessels  may  become  diseased  independently  by  chronic  processes.  They 
may  become  subject  to  thickening  or  obliterative  endarteritis,  or  other- 
wise undergo  extensive  changes. 

In  the  primary  lesion,  or    chancre,  there    is    a   small    round-celled 
infiltration   of  the  connective  tissue,  proliferation   of  the    connective- 

Fig.  120. 


A  small  artery  taken  from  a  section  of  the  tissue  depicted  in  Fig.  119,  more  highly  magnified.  Both 
the  middle  and  outer  coats  of  the  vessel  are  infiltrated  with  small  round  cells.  The  lining 
endothelial  cells  are  also  swollen. 

tissue  cells,  and  an  abundance  of  leucocytes.  (See  Fig.  119,  from  a  sec- 
tion of  a  chancre  of  the  prepuce  of  four  days'  duration.)  A  chancre  also 
shows  more  or  less  necrosis  or  degeneration  of  its  constituent  cells.  An 
uncomplicated  chancre  in  its  early  stages  is  identical  in  its  general 
structure  with  a  small  superficial  ulcer  or  patch  of  granulation,  except 
that  in  the  chancre  there  is  distinctly  more  necrosis  and  degeneration 
of  its  constituent  small  spheroidal  cells. 


490  PATHOLOGY  OF  SYPHILITIC  INFECTION,  ETC. 

The  bloodvessels  surrounding  the  chancre,  as  well  as  those  a  con- 
siderable distance  from  the  chancre,  even  in  its  earliest  stages  of  develop- 
ment, are  uniformly  changed.  (See  Figs.  120  and  121.)  The  endothelial 
cells  are  swollen  or  proliferating,  the  walls  of  the  vessels  may  be  infil- 
trated (Fig.  120),  and,  finally,  the  perivascular  spaces  are  crowded  with 
proliferating  polyhedral  cells  (Figs.  120  and  121). 

Fig.  121. 


A  vein  just  below  the  bed  of  the  same  chancre  shown  in  Fig.  120.    The  lymph-space  about  the 
vein  is  distended  with  polyhedral  cells. 

While  this  condition  of  the  bloodvessels  may  be  found  associated  with 
other  forms  of  inflammation,  especially  when  the  vessel  is  directly  in  the 
path  of  an  advancing  inflammation  or  lies  on  the  border-line  of  the  nor- 
mal tissue,  in  a  chancre  the  extensive  distribution  and  early  involve- 
ment of  the  vessels  are  characteristic.  The  extensive  distribution  of 
the  perivascular  changes,  their  topographical  arrangement,  and  early 
involvement  in  regions  slightly  beyond  the  chancre  are  the  striking 
features  in  the  initial  sore,  rather  than  any  peculiarity  of  structure  of 
the  lymph-space  lesion. 

There  are,  however,  certain  stages  in  the  development  of  chancroid 
in  which  the  perivascular  spaces  leading  from  this  form  of  sore  exhibit 
a  similar  condition,  and,  like  the  vessel-spaces  in  syphilis,  seem  to  be 
propagating  a  virus  to  the  inguinal  lymph-nodes. 

Thus,  whatever  the  causal  agent  of  syphilis  may  be,  it  very  soon 
reaches  the  perivascular  spaces  and  travels  along  these,  or  it  initiates  a 
proliferation  of  cells  in  the  lymph-spaces  about  the  vessels  which  rapidly 
propagates  and  extends  along  these  spaces  to  more  distant  parts  of  the 
body. 


PATHOLOGY  OF  SYPHILITIC  INFECTION,   ETC.  491 

This  early  and  extensive  lesion  of  the  lymph-spaces  about  the  blood- 
vessels, especially  the  smaller  veins,  enables  ns  to  understand  more  defi- 
nitely how  the  virus  of  syphilis  spreads,  how  it  travels  along  these 
lymph-spaces,  accompanying  the  vessels  to  the  root  of  the  penis,  to  the 
first  set  of  lymph-nodes  which  such  a  set  of  perivascular  lymphatics  com- 
municate with — namely,  the  inguinal  ganglia.  From  these  inguinal 
nodes  the  cell-proliferation,  in  response  to  the  syphilitic  virus,  is  propa- 
gated, it  would  seem,  to  the  lymph-nodes  in  general  throughout  the 
body  in  greater  or  less  extent,  and  in  this  way  the  general  adenopathy 
is  established. 

Finally,  in  regard  to  this  extension  of  syphilis  through  the  perivas- 
cular spaces  from  the  primary  sore  to  the  inguinal  glands,  it  may  be 
pointed  out  that  it  occurs  very  early  and  proceeds  with  great  rapidity. 
As  soon  as  the  chancre  appears  the  network  of  peripheral  perivascular 
lymph-spaces  is  already  involved,  and,  as  indicated  by  the  line  of  pro- 

Fig.  122. 


'.•  *rf&  ■  -  <:. 


■■ 
i 


\v~:      •     ■  ■•■-.w-v.  -■  .'■■. 


^#1;1 


From  a  section  of  a  chancre  of  the  prepuce  at  the  twentieth  day  from  its  first  appearance.  The 
indurating  cedenia  corresponds  to  a  distention  and  infiltration  of  the  upper  layers  of  the  derma, 
which  extends  as  a  zone,  x,  x,  x,  about  the  centre  of  the  chancre  at  a.  The  infiltration  of  the 
walls  of  the  vessels  is  also  well  exhibited,  especially  at  6. 

liferating  cells  along  the  venous  lymph-spaces,  the  virus  is  already  on 
the  path  to  the  inguinal  lymph-nodes.  It  can  be  seen,  therefore,  that 
it  is  impossible  to  stay  the  course  of  syphilis  by  excising  the  chancre. 
Not  only  the  chancre,  but  all  this  chain  of  venous  lymph-spaces  com- 
municating with  the  inguinal  lymph-node  would  also  have  to  be  removed 
to  abort  the  syphilitic  infection  of  the  body. 

The  stage  of  induration  or  indvratiny  (crfcma  remains  to  be  considered 
in  describing  the  structure  of  a  chancre.     If  a  chancre  at  the  well-pro- 


492  PATHOLOGY  OF  SYPHILITIC  INFECTION,  ETC. 

nounced  stage  of  induration  be  examined  microscopically  (Fig.  122), 
it  will  be  seen  that  the  semi-necrotic  mass  of  small  spheroidal  cells 
(Fig.  122,  a)  composing  the  bed  and  main  bulk  of  the  ulcer  is  circum- 
vallated  by  a  zone  of  oedema  and  cellular  infiltration  of  the  papillary 
portion  of  the  derma  (Fig.  122,  x,  x,  x).  Indurating  oedema,  then,  as 
the  name  implies,  is  a  wall  about  the  chancre  wherein  the  interfibrillary 
spaces  of  the  pars  papillaris  are  distended  with  fluid  and  small  round 
cells  (Figs.  122  and  123). 

Fig.  123. 


?mmmi 


>:«: 


From  a  portion.of  the  section  corresponding  to  Fig.  191,  more  highly  magnified.    The  interfibril- 
lary spaces  of  the  upper  layers  of  the  derma  are  distended  with  fluid  and  small  round  cells. 

To  recapitulate  briefly  the  series  of  changes  in  a  chancre :  When  the 
causal  agent  of  syphilis,  presumably  some  form  of  bacterium,  enters 
through  the  skin  or  mucous  membrane,  it  excites  local  leucocytosis  and 
exudative  inflammation,  with  more  or  less  necrosis;  there  are  also  pro- 
liferation of  the  connective-tissue  cells,  a  propagation  of  proliferating 
cells  along  the  perivascular  lymph-spaces,  and  later  a  wall  of  infiltration 
and  oedema  of  the  upper  corium  layers  formed  about  the  periphery  of 
the  ulcer  corresponding  to  the  stage  of  indurating  oedema.  Finally,  the 
sore  tends  to  heal  and  become  converted  into  scar-tissue. 

Following  the  initial  sore  there  may  be  inflammation  of  the  lymph- 
nodes,  of  the  skin  and  mucous  membranes,  of  the  bones,  and  of  several 
viscera,  which  are  structurally  similar  in  each  case. 

Although  not  confined  strictly  to  the  secondary  stage  of  syphilis,  the 
gummy  tumors,  or  gummata,  form  the  distinctive  feature  of  this  stage,  and, 
structurally,  are  characteristic  of  syphilis.  A  small  gumma  consists  of 
a  mass  of  small  spheroidal  and  epithelioid  cells,  and  occasionally  giant 


PATHOLOGY  OF  SYPHILITIC  INFECTION,  ETC.  493 

cells.  Small  gummata  may  resemble  miliary  tubercles  so  closely  that 
from  microscopical  appearances  alone  it  is  difficult  to  distinguish  them 
apart.  The  larger  gummata  have  rather  characteristic  gross  appear- 
ances :  to  the  naked  eye  they  appear  as  grayish-white,  rather  firm, 
spherical  nodules ;  they  generally  have  a  firm,  cheesy  centre  and  a  trans- 
lucent pearly  capsule  merging  into  the  surrounding  tissue.  In  structure 
such  a  gumma  has  a  granular  necrotic  centre  surrounded  by  a  connective- 
tissue  envelope  which  is  generally  infiltrated  with  small  round  cells  and 
sends  off  prolongations  into  the  surrounding  tissue,  so  that  when  situated 
in  the  viscera  the  gumma  is  quite  sharply  circumscribed.     (See  Fig.  124.) 

Fig.  124. 


•V,W-":  -  <■?■* ■■+■■:■  '■';■  •;  ^- ■•■><,; ' 

■■<;■:  ••.'-.V.-...VU--.'"  :-.'-o-.-.v;  ::,.■;■,■■.■■:■:'-■:■;■;■;'.<<,.-■■.  ,'ri-: '■';■•-,' V 


r','1  r.-f-f 


\\.--    -  I;'  V- 

"'IV 

A  gumma  of  the  liver  which  has  a  cheesy  centre,  a  connective-tissue  capsule  with  processes 
extending  into  the  surrounding  tissue,  and  infiltration  of  the  same  with  small  round  cells. 

This  description  outlines  the  broader  features  of  syphilitic  inflamma- 
tion as  a  phase  or  variety  of  inflammation  in  general ;  but  we  cannot  in- 
terpret these  morbid  changes  very  intelligently  until  the  micro-organism 
of  syphilis  is  discovered  and  the  nature  and  action  of  its  toxin  are 
learned. 

The  chronic  production  of  neuroglia  in  the  central  nervous  system, 
due  to  syphilis,  should  not  be  confused  with  a  more  specialized  form  of 
syphilis  of  the  nervous  system  which  not  infrequently  occurs  in  un- 
treated or  improperly  treated  cases.  This  form  of  involvement  of  the 
nervous  system,  termed  usually  "  syphilis  of  the  nervous  system," 
may  occur  moderately  early  in  the  disease.  It  has  a  subacute  character, 
is  prone  to  occur  in  a  disseminated  form,  especially  in  the  spinal  cord, 
and  consists  of  masses  of  small  round  or  fusiform  cells,  which  involve 
either  the  gray  or  the  white  matter. 


CHAPTER   XXVII. 

VEHICLES  OF  INFECTION  IN  SYPHILIS. 

Clinical  observation  and  experimental  inoculations  have  proved 
that  the  secretion  of  the  initial  lesion  contains  in  a  high  degree  the  virus 
of  syphilis.  It  is  from  the  secretions  of  the  initial  lesion  that  infection 
with  the  disease  is  derived  in  the  great  majority  of  cases. 

Equally  as  virulent  are  the  secretion  and  the  tissue-detritus  of  the 
secondary  lesions  known  as  condylomata  lata  and  mucous  patches  which 
occur  so  frequently  in  and  about  the  mouth  and  face  and  on  the  genital 
and  anal  regions. 

Experimental  inoculations  (of  course,  upon  human  subjects,  since 
animals  are  immune)  have  proved  that  the  secretions  from  pustules, 
from  syphilitic  tubercle,  and  from  ulcers  and  papules  produce  typical 
syphilitic  infection  in  the  person  operated  upon. 

Numerous  experimental  inoculations  with  the  blood  of  syphilitics 
have  given  rise  to  well-marked  instances  of  syphilitic  infection. 
Clinical  observation  has  frequently  confirmed  the  results  of  experimenta- 
tion as  to  the  infectious  quality  of  the  blood  of  syphilitic  subjects. 

It  seems,  however,  that  it  is  only  in  the  quite  early  period  of  the 
disease,  when  the  infection  is  active,  that  the  blood  is  most  poisonous. 
With  the  decline  of  the  disease,  particularly  when  it  has  been  profoundly 
modified  by  mercurial  treatment,  the  blood  becomes  more  and  more 
feebly  infectious,  so  that  in  general  after  one  or  two  years'  thorough 
treatment  it  is  harmless.  It  is,  therefore,  the  least  infectious  of  all 
syphilitic-bearing  secretions  or  fluids. 

The  initial  lesion  of  syphilis,  therefore,  has  its  origin — 

1.  In  the  secretion  of,  and  organized  matter  derived  from,  a  previous 
hard  chancre  or  initial  lesion  ; 

2.  In  the  secretions  and  the  organized  matter  of  the  secondary  lesions 
of  syphilis,  whether  of  the  skin  or  of  the  mucous  membrane  :  that  of 
mucous  patches  and  condylomata  lata  has  been  shown  to  be  especially 
contagious,  and  that  of  papules  and  tubercles  less  so  ; 

3.  In  the  secretions  of  hereditary  syphilis  in  its  active  state,  which 
arise  from  buccal  mucous  patches  or  erosions,  condylomata  lata  of  the 
mouth  or  anus,  and  also  from  ulcerated  tubercular  lesions ; 

4.  In  the  blood  of  persons  in  the  active  state  of  syphilis :  the  lymph 
also  may  communicate  the  disease. 

Such   is  the  bland,  unirritating  character  of  the  various  infecting 

494 


VEHICLES   OF  INFECTION  IN  SYPHILIS.  495 

secretions  of  syphilis  that  it  is  very  probable  a  door  of  entry,  such  as  a 
fissure,  an  abrasion,  or  other  denuded  surface,  perhaps  so  small  as  not  to 
be  visible,  is  generally  necessary  for  their  introduction.  It  is  claimed, 
however — and  no  doubt  reasonably — that  the  virus  may  penetrate  the 
thin,  soft,  and  moist  epithelium  of  mucous  membrane.  Clinical  facts 
show  clearly  that  it  may  penetrate  into  the  orifices  of  the  mucous  and 
sebaceous  follicles,  and  in  them  take  root. 

Syphilis  pursues  essentially  the  same  course  whether  derived  from  a 
primary  or  secondary  lesion;  in  the  latter  case,  as  in  the  former,  the 
initial  lesion  is  a  chancre. 

It  is  conceded  by  most  authorities  that  only  the  secretions  of  secondary 
lesions  are  infectious,  and  those  of  the  tertiary  period  are  inert.  Unfor- 
tunately, we  are  not  in  possession  of  enough  knowledge  upon  this 
subject  to  make  positive  statements.  It  is  very  certain  that  when  the 
disease  is  active,  as  shown  by  the  extent  and  severity  of  its  lesions,  the 
secretions  of  its  bearer  are  markedly  infectious.  As  time  passes  the 
morbid  condition  tends  in  most  cases  to  attenuation,  and  the  infectious 
nature  of  the  secretions  grows  less.  There  is  a  natural  tendency  in 
very  many  cases  for  the  disease  to  grow  less  and  less  active  until 
in  the  end  its  virulence  may  cease.  This  gradual  extinction  of  the 
disease  may  take  place  spontaneously  without  the  aid  of  therapeutics, 
but  this  natural  involution  can  never  be  relied  upon.  The  most 
potent  element  in  curing  the  disease  and  in  rendering  the  subject 
incapable  of  infecting  others  is  active  and  energetic  treatment  kept 
up  for  the  first  two  years  or  longer.  Under  proper  treatment  the 
infectiousness  of  the  disease  quite  rapidly  diminishes,  and  finally  becomes 
extinct. 

It  is  very  probable  that  the  secretions  and  tissue-elements  of  many 
of  the  tertiary  lesions,  particularly  when  they  are  active  and  numerous 
and  occurring  within  three,  four,  or  five  years,  may  be  endowed  with  a 
virulent  power,  and  that  they  may  lose  this  virulence  at  later  periods. 

The  normal  secretions  of  a  syphilitic  subject  do  not  of  themselves 
contain  any  virulent  principle.  They  may  be  contaminated  by  admix- 
ture of  secondary  secretions  and  of  the  tissue-elements  of  secondary 
lesions,  and  by  blood. 

The  semen  of  a  man,  even  in  the  secondary  stage  of  syphilis,  is  not 
per  se  an  infectious  fluid.  It  may  remain  on  the  mucous  membrane  of 
the  female  genitals  for  a  long  time  without  causing  any  result.  It  does 
not  contain  an  active  virulent  principle. 

When  the  semen  of  a  man  suffering  from  an  active  form  of  syphilis 
fecundates  the  female  ovum,  in  the  majority  of  cases  he  transmits  the 
disease  to  the  infant.  In  this  way  alone  is  the  semen  of  the  syphilitic 
man  dangerous. 


496  VEHICLES  OF  INFECTION  IN  SYPHILIS. 

MODES  OF  INFECTION. 

These  are,  first,  direct  contact ;  second,  mediate  infection  ;  and  third, 
hereditary  transmission.  We  are  warranted  in  assuming  that  in  all 
instances  of  syphilitic  infection  there  is  a  lesion  of  continuity  or  gap  in 
the  epithelium  of  the  skin  or  mucosa. 

Infection  by  direct  contact  is  the  most  common  mode  of  contamina- 
tion, and  the  sexual  act  is  the  one  by  which  the  disease  is  in  most  cases 
given  and  received. 

Direct  syphilitic  infection  frequently  results  from  unnatural  and 
beastly  methods  of  indulgence  between  persons  of  the  same  and  the 
opposite  sex.  In  this  way  are  developed  chancres  of  the  anus,  of  the 
tongue,  of  the  folds  between  the  breast  and  the  sides  of  the  chest,  of  the 
axillae,  and  of  the  tonsils.  I  have  known  several  instances  in  which 
men  were  infected  upon  the  penis  by  contact  ab  ore  with  men  or  women 
who  had  syphilitic  lesions  in  their  mouths.  Several  men  have  told  me 
that  they  followed  this  practice,  thinking  that  by  it  they  would  escape 
syphilitic  infection. 

Kissing  also  is  a  prolific  source  of  infection,  and  as  a  result  of  this 
act  chancres  of  various  parts  of  the  body  are  produced. 

Not  infrequently  hereditarily  syphilitic  children  infect  their  nurses 
upon  the  nipple  from  mucous  patches  in  the  mouth.  Then,  again, 
children  have  been  infected  from  chancres  or  condylomata  lata  on  the 
nipples  of  their  nurses. 

I  have  a  number  of  times  seen  chancres  of  the  nipple  in  women 
produced  by  suction  of  a  man  having  mucous  patches  in  his  mouth. 
Then,  again,  I  have  seen  two  instances  of  chancre  of  the  nipple  in  men 
contracted  from  the  mouths  of  syphilitic  women  in  the  act  of  suction. 

There  are  in  literature  many  cases  reported  in  which  syphilitic  mid- 
wives,  usually  of  the  lower  classes,  have  infected  nursing  women  with 
syphilis  upon  the  nipple  in  the  act  of  suction  or  drawing  the  breast, 
which  they  sometimes  perform. 

In  some  European  countries,  particularly  Roumania,  a  singular 
method  of  transmission  is  said  to  occur.  It  is  the  custom  there  to  attrib- 
ute all  affections  of  the  eyes  to  foreign  bodies,  for  the  relief  of  which 
there  is  a  class  of  women,  called  "leeching  oculists,"  who  suck  or 
cleanse  the  eyelids  with  their  tongues.  One  of  these  women,  having 
mucous  patches  in  her  mouth,  conveyed  the  disease  to  many  persons. 

Syphilitic  infection  is  sometimes  produced  during  brawls  and  fights 
in  which  an  infected  person  bites  his  or  her  antagonist.  In  this  way, 
also  in  exuberant  embraces  between  the  sexes,  one  or  the  other  some- 
times becomes  syphilitic. 

Surgeons   very  frequently  contract  syphilis  on  cuts  and   abrasions 


31  ODES  OF  INFECTION.  497 

about  the  fingers  and  hands  when  operating  upon  syphilitic  subjects. 
Physicians,  accoucheurs,  and  midwives  also  frequently  contract  syphilis 
in  vaginal  examinations  of  infected  women.  They,  in  turn,  have  been 
known  to  spread  infection  far  and  wide  in  an  epidemic  form  by  infect- 
ing women  during  examinations  about  the  genitals  by  means  of  their 
finger-chancres.  From  the  infected  wives  the  husbands,  children,  and 
friends  have  become  contaminated. 

There  are  many  cases  in  literature  in  which  syphilis  has  been 
communicated  in  the  operation  of  tattooing,  the  operator  using  his 
own  saliva,  which  was  contaminated  by  the  secretion  of  mucous  patches. 

In  the  operation  of  skin-grafting  the  disease  has  been  given  to  the 
person  operated  upon  by  the  graft,  which  was  derived  from  a  syphilitic 
subject. 

Dentists  sometimes  contract  syphilis  from  the  mouths  of  infected 
subjects,  and  it  is  very  probable  that  the  latter  are  sometimes  infected  by 
means  of  instruments  smeared  with  active  syphilitic  secretions.  It  is  a 
good  rule  to  avoid  the  services  of  a  careless  or  uncleanly  dentist. 

In  ritual  circumcision,  when  the  flow  of  blood  is  stanched  by  im- 
mersion of  the  infant's  penis  in  the  mouth  of  the  operator,  there  is 
danger  of  syphilitic  infection. 

In  these  days,  when  pure  bovine  virus  is  used  in  vaccination,  there 
is  no  possibility  of  the  transmission  of  syphilis  by  that  secretion.  The 
danger  arises  in  carelessness  on  the  part  of  the  operator  in  using  a 
soiled  scarificator.  In  the  hurry  incident  to  the  vaccination  of  many 
persons  the  surgeon  is  liable  to  become  careless  and  to  fail  to  cleanse  the 
instrument  after  each  operation.  In  this  way  it  may  happen  that  a 
syphilitic  patient  may  be  vaccinated  and  the  instrument  used  may  be- 
come smeared  with  blood  and  tissue-debris.  Then,  if  this  instrument 
is  used  to  scarify  the  next  subject  without  having  been  cleansed  or  sub- 
jected to  a  flame,  the  blood  and  the  tissue-elements  are  firmly  im- 
planted upon  and  into  his  or  her  excoriated  surface,  and  it  is  pretty 
certain  that  syphilitic  infection  will  be  produced. 

Mediate  Infection. — Tn  this  form  of  infection  the  disease  is  com- 
municated by  means  of  articles,  implements  or  instruments  which  have 
become  smeared  or  impregnated  with  the  syphilitic  virus.  In  cases 
of  this  form  of  infection  the  contaminated  parts  are  most  commonly  the 
lips,  the  gums,  the  mouth,  and  the  eyelids.  Any  part  of  the  integu- 
ment and  of  the  genitals  may  also  be  the  seats  of  infection.  The  fol- 
lowing list  includes  most  of  the  articles  and  instruments  which  have 
been  found  to  be  the  agents  of  mediate  syphilitic  infection  :  cigars, 
cigar-  and  cigarette-holders,  pipes,  tooth-brushes,  tooth-powders,  drink- 
ing utensils,  knives,  forks,  spoons,  razors,  towels,  sponges,  pillows, 
masks,  gloves,  wash-rags,  linen  thread,  silk  thread,  pins,  needles, 
32 


498  VEHICLES   OF  INFECTION  IN  SYPHILIS. 

children's  toys,  nursing-bottles,  rubber  tubes,  babies'  rubber  rings, 
trousers,  women's  drawers,  bandages,  surgical  and  cupping  instruments, 
manicure  instruments,  syringes,  scarifiers,  dental  implements  and  appli- 
ances, caustic-holders,  blowpipes,  paper-cutters,  lead-pencils,  speaking- 
trumpets,  musical  instruments,  fish-horns,  whistles,  the  mouth-piece  of 
the  telephone,  chewing-gum,  and  even  pastilles  and  candy. 

There  is  a  mode  of  syphilitic  infection  which  has  not  yet  been 
described — it  is  really  auto-infection.  It  generally  occurs  in  this  way  : 
A  man,  fearing  to  contract  venereal  diseases  or  for  other  reasons, 
contents  himself  with  a  digital  exploration  or  fondling  of  the  female 
genitals.  Upon  the  latter  condylomata  lata  or  syphilitic  excoriations 
being  present,  the  fingers  of  the  man  become  soiled  with  their  secretion. 
Then  by  accident  the  virus  is  transferred  by  the  finger  or  fingers  of  the 
man  to  some  other  part  of  his  own  body,  generally  by  scratching  or 
picking.  In  this  mode  the  finger  becomes  a  medium  of  infection,  and 
the  infected  parts  are  usually  the  alas  nasi,  the  tip  of  the  nose,  the  chin, 
the  cheek,  the  neck,  the  arm,  and  the  back  of  the  hand. 

It  is  rather  revolting  to  one's  feeling  to  put  the  matter  on  paper,  but 
the  interests  of  medical  science  certainly  warrant  the  recital.  I  have 
seen  two  cases  in  educated  and  religious  people  in  which  the  weight  of 
evidence  strongly  pointed  to  the  origin  of  their  labial  chancres  in  the 
communion  cup.  Knowing  as  we  do  so  well  that  many  innocent  per- 
sons, particularly  women,  become  unconscious  victims  of  syphilitic  in- 
fection and  still  follow  the  observances  of  a  religious  life,  it  is  not  far- 
fetched to  assume  that  their  diseased  mouths  may  contaminate  the 
sacred  chalice. 


CHAPTEK   XXVIII. 

THE    CHANCRE,  OR  THE  INITIAL  LESION  OF  SYPHILIS. 

At  the  end  of  the  first  period  of  incubation  the  first  evidence  of 
syphilitic  infection  shows  itself  in  the  form  of  a  small  and  usually  in- 
nocent-looking lesion,  which,  as  we  have  seen,  is  called  the  initial  lesion, 
the  Hunterian  chancre,  and  by  other  terms.  In  the  great  majority  of 
cases  the  initial  lesion  is  seated  on  the  sexual  organs,  and  it  is  then 
termed  genital  chancre,  while  that  found  elsewhere  on  the  body  is 
called  extragenital  chancre. 

This  first  period  of  incubation,  as  we  have  seen,  varies  in  length 
between  twelve  and  thirty,  and  exceptionally  forty,  fifty,  sixty,  and 
seventy  days.  It  follows,  therefore,  that  if  a  man  seeks  information 
as  to  his  chances  and  condition  after  a  suspected  or  suspicious  coitus, 
he  should  be  told  that  at  any  time  between  the  fifteenth  and  sixtieth  or 
seventieth  days  the  chancre  may  appear,  and  that  he  must  be  constantly 
on  the  watch  for  it,  for  his  own  benefit  in  promptly  seeking  treatment 
and  for  the  protection  of  women  with  whom  he  may  have  intercourse. 
In  the  vast  majority  of  cases  it  is  not  necessary  to  prolong  a  man's 
anxiety  and  even  agony  beyond  thirty  days. 

It  is  very  important  that  clear  ideas  should  be  held  as  to  the  indura- 
tion of  chancres.  The  terms  hard  and  indurated  chancres  act  as  stumbling- 
blocks  to  very  many  physicians  in  their  estimate  of  the  nature  of  genital 
ulcers  and  lesions.  The  tendency,  I  observe,  has  been  not  so  much  to 
form  an  opinion  by  a  consideration  of  the  physical  appearance  of  a 
given  lesion  as  by  its  relative  hardness  and  softness  of  structure. 
When  a  genital  lesion  is  brought  to  the  attention  of  the  surgeon  he 
instinctively  feels  of  it,  and  in  general,  if  he  can  find  no  resistance  or 
induration,  he  at  once  pronounces  it  to  be  a  soft  sore,  or  chancroid.  In 
this  way  mistakes  in  diagnosis  are  made  every  day.  Now,  at  the  outset 
it  is  important  to  know  that  induration  is  not  present  in  primary  syphi- 
litic lesions  in  their  early  days.  The  cell-proliferation  which  gives  rise 
to  the  symptom  of  induration  goes  on,  as  a  general  rule,  slowly,  and  it 
is  seldom  clearly  and  sharply  appreciable  before  the  tenth  day  ;  and  in 
general  terms  it  may  be  stated  that,  as  a  rule,  fourteen  days  elapse 
before  sharply  marked,  circumscribed,  easily  appreciable  induration  is 
present  in  a  primary  syphilitic  sore. 

In  a  large  majority  of  cases  there  is  but  one  chancre  or  initial  lesion, 
but  it  is  not  uncommon  to  see  two  or  three,  and  exceptionally  four, 

499 


500      THE  CHANCRE,    OR   THE  INITIAL  LESION  OF  SYPHILIS. 

six,  seven,  or  even  more,  initial  lesions.  There  is  a  deep-rooted  and 
widely  prevalent  view  in  the  minds  of  many  medical  men  that  the 
initial  lesion  is  invariably  solitary,  and  that  when  several  genital  ulcers 
and  even  excoriations  are  seen  they  must  be  chancroids.  As  a  result 
of  this  an  incalculable  number  of  mistakes  in  diagnosis  are  constantly 
made,  which  result  in  disappointment  and  often  disgust  to  the  patient, 
and  in  deep  chagrin  to  the  surgeon.  The  penis,  the  female  genitals,  the 
female  breasts,  and  the  cephalic  regions  are  the  parts  upon  which  mul- 
tiple lesions  are  most  commonly  found. 

In  the  male,  chancres  are  found  on  the  glans,  on  the  prepuce,  on  the 
skin  of  the  penis,  on  various  parts  of  the  penis,  involving  the  meatus, 
within  the  urethra  (not  visible  on  forced  separation  of  the  lips  of  the 
meatus,  but  recognized  by  palpation,  inflammation  of  the  lymphatics, 
etc.),  on  the  scrotum  and  penoscrotal  angle,  the  anus,  the  lips,  the 
tongue,  the  gums  and  hard  palate,  the  pharynx  (including  the  tonsils), 
the  nose,  the  pituitary  membrane,  the  eyelids,  the  fingers,  and  on  the 
legs. 

APPEARANCE  OF  THE  INITIAL  LESION,  OR  CHANCRE. 

In  its  early  stages  the  chancre  is  such  a  seemingly  trifling  and  inno- 
cent lesion  that  its  virulence  is  very  apt  to  be  overlooked. 

There  are  six  conditions  under  which  chancres  appear  at  their  very 
beginning:  these  are — first,  the  chancrous  erosion;  second,  the  silvery 
spot;  third,  the  dry  papule  or  patch;  fourth,  the  umbilicated  papule  or 
nodule  or  follicular  chancre;  fifth,  the  purple  necrotic  nodule;  and, 
sixth,  the  ecthymatous  chancre. 

Besides  the  six  type-forms,  there  are  the  following  varieties  which 
are  due  to  certain  changes  to  which  the  primary  sore  is  liable :  the  ulcus 
elevatum,  multiple  herpetiform  chancre,  the  parchment  chancre,  the 
annular  chancre,  the  indurated  nodule  or  mass,  the  chancre  with  cream- 
green  membrane,  and  infecting  balanoposthitis. 

The  Chancrous  Erosion. — The  chancrous  erosion,  by  far  the  most 
common  form,  is  really  the  primordial  lesion  from  which  all  chancres 
develop.  It  begins  as  a  minute,  sharply  rounded  excoriated  spot,  the 
surface  of  which  is  on  a  level  with  the  surrounding  parts.  It  looks 
exactly  like  an  erosion  or  shedding  of  the  uppermost  epithelial  layer. 
(See  Plate  XXYIIL,  Fig.  1.)  The  color  is  a  dull  red,  which  later 
may  assume  a  coppery  hue. 

This  form  of  chancre  is  most  marked  on  the  internal  surface  of  the 
prepuce,  by  which  it  is  protected  from  the  air,  irritation,  and  friction; 
and  it  is  in  this  situation  that  it  is  most  frequently  met  with.  It  has 
generally  a  circular  or  ovoid,  but  sometimes  irregular,  outline.  Its  floor 
is  but  slightly,  if  at  all,  excavated,  and  occasionally  is  even  elevated 


PLATE  XXVIII. 


HARD    CHANCRES. 


APPEARANCE  OF  THE  INITIAL   LESION,    OR   CHANCRE.       501 

above  the  surrounding  integument.  It  has  a  smooth,  polished  surface, 
usually  destitute  of  granulations,  but  sometimes  slightly  granular  and 
velvety,  from  which  considerable  serous  fluid  oozes,  particularly  on 
manipulation.  Its  surface  is  destitute  of  the  persistent  and  adherent 
exudation  of  the  chancroid.  At  times  it  is  dark  or  even  black,  owing 
to  molecular  gangrene.  This  lesion  sometimes  becomes  decidedly 
saucer-shaped.  When  extensive  and  persistent  these  chancres  are  called 
beefsteak  chancres.     (See  Plate  XXIV.,  Fig.  4.) 

Usually  there  is  but  one  such  lesion ;  but  there  may  be  three,  four, 
or  five,  and  very  exceptionally  more  than  a  dozen.  When  a  number 
of  these  chancrous  erosions  are  grouped  in  the  corymbus-like  form 
peculiar  to  herpetic  vesicles,  for  which  they  are  very  liable  to  be  mis- 
taken, they  are  called  multiple  herpetiform  changes.  These  chancres 
have  a  diameter  of  a  line  or  less;  they  are  small  round  excoria- 
tions, of  a  deep-red,  sometimes  coppery  hue,  which  bleed  readily  and 
have  a  very  slight  induration  of  their  bases.  The  induration  usually 
increases  at  a  later  period.  From  five  to  fourteen  chancres  may  be 
observed  upon  the  prepuce  or  glans.  In  their  first  stage  the  diagnosis 
is  difficult,  but  the  absence  of  itching  and  burning,  their  dark  color,  and 
their  chronicity  are  points  which  aid  in  distinguishing  them  from  herpes. 
Another  important  feature  is  that  their  surface  is  smooth  and  shining. 
Moreover,  induration  of  the  inguinal  ganglia  is  soon  developed. 

The  chancrous  erosion  is  constantly  mistaken  for  herpes  progenitalis, 
and  is  in  many  instances  pronounced  by  the  surgeon  to  be  a  simple 
chafe  or  excoriation.  Consequently,  it  is  always  well  to  be  cautious 
and  slow  in  expressing  opinions  concerning  seemingly  insignificant 
lesions  of  the  genitals.  The  smooth,  shining  surface  of  the  syphilitic 
lesion  is  in  many  cases  diagnostic,  but  it  may,  owing  to  extraneous 
influences,  become  granular  and  perhaps  ulcerated.  It  has  been  claimed 
that  herpetic  vesicles  give  issue,  particularly  if  pressed  between  the 
finger  and  thumb,  to  a  copious  serous  secretion,  and  that  this  does  not 
occur  in  cases  of  the  chancrous  erosion  ;  therefore,  that  this  is  a  diagnostic 
sign  between  herpes  and  the  syphilitic  lesion.  The  truth  is  that  the 
chancrous  erosion  gives  issue  to  far  more  serum  than  does  the  herpetic 
lesion. 

When  it  simply  remains  a  superficial,  compact  lesion,  the  induration 
is  spread  out  into  a  disk-like  mass,  and  the  lesion  is  then  called  the 
parchment-like  chancre.  On  the  other  hand,  when  the  syphilitic  process 
dips  down  into  the  subcutaneous  connective  tissue,  and  is  complicated 
with  indurating  oedema,  the  chancrous  erosion  becomes  the  indurated 
nodule.  Parchment-chancres  are  mostly  found  on  the  integument 
of  the  penis  and  sometimes  in  the  vulva.  Indurated  chancres  are 
mostly  found   in  the   sulcus   coronarius,  particularly  near  the  framuni. 


502      THE  CHANCRE,    OR   THE  INITIAL  LESION  OF  SYPHILIS. 

(See  Plate  XXVIII.)  When,  owing  to  excessive  cell-increase,  the 
chancrons  erosion  becomes  salient  above  the  level  of  the  "part,  it  is  called 
ulcus  elevatum. 

In  many  cases  these  flat  or  elevated  chancres  become  covered  with  a 
false  membrane,  very  incorrectly  called  "  diphtheritic,"  which  is  peculiar 
in  having  a  color  which  is  a  mixture  of  a  cream  with  a  light-green  tint. 
This  membrane  may  exist  for  longer  or  shorter  periods.  As  it  grows 
old,  if  not  shed,  it  sometimes  becomes  in  whole  or  in  part  of  a  brown  or 
brownish-black  color.  It,  as  a  rule,  does  not  cover  the  whole  of  the 
chancrous  surface,  but  rather  its  central  portions,  leaving  the  margins 
free.  This  film-like  or  more  dense  membrane  is  very  distinctive,  even 
diagnostic  of  chancres.  It  is  well  shown,  as  to  extent  and  color,  in 
Fig.  3,  Plate  XXVIII.,  seated  on  a  well-marked  indurated  nodule.  (In 
Figs.  2,  4,  and  8  also  it  is  well  portrayed  from  my  own  cases.)  This 
membrane  often  becomes  discolored  by  the  admixture  of  dirt  and  also 
as  a  result  of  minute  hemorrhages.  Thus  in  Fig.  5  the  membrane  is 
darker  than  it  is  in  the  previous  figures,  while  in  Fig.  7  it  reaches  its 
acme.  This  membrane  may  remain  on  the  sore  for  a  short  or  a  long 
time.  If  antiseptic  lotions  or  iodoform  is  used,  it  melts  away  and  an 
erosive  chancrous  surface  is  left.  This  lesion  may  very  properly  be 
called  the  chancre  with  the  cream  and  green-colored  membrane. 

In  some  rare  cases  these  chancres  become  necrotic,  an  accident  which 
is  well  shown  in  Fig.  6,  Plate  XX  VIII. 

The  Silvery  Spot. — This  lesion,  first  described  by  me,  is  very  rare 
and  presents  well-marked  features.  It  generally  occurs  on  the  glans  and 
on  the  lips  of  the  meatus,  and  at  first  it  looks  as  if  a  pinhead-sized  spot 
of  mucous  membrane  had  been  touched  with  carbolic  acid  or  nitrate  of 
silver.  Examined  with  a  magnifying  glass,  there  is  no  other  change 
evident  than  the  peculiar  staining  of  the  superficial  epithelial  cells.  The 
silvery  lesion  increases  slowly  but  visibly  day  by  day,  and  preserves  its 
integrity  of  surface  until  it  reaches  an  area  of  about  a  line,  when,  coin- 
cidently  with  the  subjacent  induration,  which  has  been  simultaneously 
developing,  and  which  has  slowly  raised  it  up,  it  disappears,  and  is  re- 
placed by  a  smooth,  shiny  surface  like  that  of  the  chancrous  erosion  or 
that  of  some  indurated  nodules. 

The  Dry  Papule. — This  chancre  is  usually  found  upon  the  glans  or 
prepuce  when  not  in  a  state  of  coaptation,  and  consequently  is  always 
developed  in  a  very  dry  condition.  As  a  rule,  it  is  solitary,  and  is  not 
uncommonly  seen  on  persons  who  have  been  circumcised  or  who  have 
short  prepuces.  It  is  found  upon  the  integument  of  the  penis,  about 
the  pubes,  on  the  thighs,  and  elsewhere  upon  the  body.  (See  Fig.  1, 
Plate  XXX.) 

A  modification  of  this  form  of  the  initial  lesion  has  been  described 


VARIETIES   OF  CHANCRE.  503 

"  diphtheroid  as  of  the  glans,"  a  very  incorrect  term,  since  neither  in 
appearance  nor  course  does  the  lesion  at  all  resemble  diphtheritic  mem- 
brane, which  is  always  seated  on  an  excoriated  surface.  It  consists  of 
patches  of  a  glistening  grayish-white  color,  presenting  either  a  greasy 
sensation  to  the  fingers  or  something  like  that  of  wet  chamois-skin.  The 
lesion  is  slightly  salient,  not  indurated,  involves  the  superficial  tissues, 
the  mucous  membrane  of  the  glans  and  sometimes  of  the  prepuce,  has 
sharply  defined  borders,  and  gives  rise  to  no  secretion  from  its  surface. 

The  umbilicated  papule  or  follicular  chancre  is  a  rare  form  of 
the  initial  lesion,  of  which  I  have  seen  six  cases.  It  begins  as  a 
pinkish  elevation  of  the  size  of  a  milium,  with  a  minute  depression  in 
the  centre,  which  grows  slowly  and  assumes  in  form  the  appearance  of 
a  tumor  of  molluscum  sebaceum.  Further  increase  takes  place  until  a 
pea-sized  tumor  is  formed.  As  the  lesion  grows  the  central  depression 
becomes  broader  and  deeper,  until  when  fully  developed  the  chancre 
becomes  cup-shaped  and  looks  as  if  set  in  the  mucous  membrane,  with 
its  borders  markedly  elevated. 

The  Necrotic  Nodule. — The  purple  necrotic  nodule  is  also  a  rare 
form  of  the  initial  lesion.  It  is  always,  according  to  my  experience, 
found  upon  the  glans  penis  and  in  the  coronary  sulcus.  It  begins  as  a 
small  dark-red  spot  which  soon  becomes  elevated ;  as  it  grows  its  color 
deepens ;  it  becomes  salient  and  roundly  convex  on  its  surface.  This 
chancre  is  prone  to  necrotic  degeneration. 

VARIETIES  OF  CHANCRE. 

The  EcthymatOUS  Chancre. — The  ecthymatous  chancre  is  simply 
a  chancre  which  becomes  covered  with  a  pus-crust.  It  is  developed 
from  the  dry  papule  or  the  chancrous  erosion  or  the  ulcus  elevatum. 
The  surface  of  the  lesion  becomes  mildly  exulcerated,  and  slowly  a  flat 
crust  forms  which  is  of  a  brownish-black  or  greenish-brown  color. 
(See  Plate  XXVIII. ,  Fig.  10.)  The  crust  is  formed  of  pus-cells,  tissue- 
detritus,  and  numerous  microbes.  The  term  "ecthymatous"  might  con- 
vey the  impression  that  the  lesion  begins  as  a  pustule  ;  this  it  never  does. 
It  is  simply  a  hard  chancre  which  is  mildly  irritated  in  its  surface,  and 
as  a  result  slowly  becomes  covered  with  a  crust.  In  this  particular  only 
does  this  lesion  resemble  ecthyma.  This  form  of  chancre  is  found  upon 
cutaneous  surfaces,  particularly  of  the  penis  and  juxtagenital  parts.  (See 
Fig.  2,  Plate  XXX.) 

The  Annular  Chancre. — The  term  "annular  chancre"  is  applied 
to  primary  lesions  in  which  the  great  part  of  the  new  growth  is  de- 
veloped in  a  ring-like  form,  the  centre  of  the  lesion  being  less  thickened 
and  infiltrated.  In  some  cases  this  ringed  development  is  strikingly 
apparent,  in  others  it  is  less  so.     This  form  of  chancre  is  found  on  the 


504      THE  CHANCRE,    OR   THE  INITIAL  LESION  OF  SYPHILIS. 

internal  surface  of  the  prepuce,  sometimes  on  the  glans,  and  again  on 
cutaneous  surfaces,  particularly  of  the  penis.  The  annular  develop- 
ment of  the  chancre  is  well  shown  in  Fig.  4,  Plate  XXVIII.,  in  the 
large  lesion.  It  must  be  remembered  that  the  tissue  within  the  ring  is 
hyperplastic,  but  much  less  so  than  its  margin. 

Infecting  Balanitis. — By  the  term  "  infecting  balanitis"  is  under- 
stood a  development  of  the  initial  lesion,  in  a  diffuse  plate-like  form, 
in  the  mucous  layer  of  the  prepuce,  and  sometimes  also  in  the  super- 
ficies of  the  glans.  This  lesion  usually  begins  as  a  goodly  sized  chan- 
crous  erosion,  which  spreads  peripherally  until  perhaps  the  whole  pre- 
puce is  involved  in  the  hyperplastic  process.  The  appearance  of  the 
parts  is  then  striking.  The  prepuce  is  thickened,  usually  of  a  dull, 
deep  red,  and  has  a  velvety  excoriated  appearance.  Retraction  of  the 
prepuce  becomes  difficult  and  perhaps  impossible.  Not  infrequently 
this  condition  of  the  prepuce  coexists  and  merges  with  a  circumscribed 
indurated  nodule  or  nodules  at  the  coronal  sulcus  or  frsenum.  (See 
Fig.  1,  Plate  XXX.) 

The  Mixed  Chancre. — This  term  is  applied  to  certain  hard  chan- 
cres whose  appearances  have  been  so  changed  by  chancroidal  pus  or  by 
pus-microbes  and  their  resulting  ulceration  that  they  resemble  chancroids 
on  the  surface,  while  they  present  more  or  less  distinctly  the  induration 
of  the  specific  lesion.  It  is  important  to  diagnosticate  correctly  these 
hybrid  chancres  from  chancroids  complicated  with  much  subcutaneous 
oedema.     (See  Fig.  4,  Plate  XXIX.) 

NATURE  OF  THE  SECRETION. 

The  secretion  of  the  syphilitic  chancre  is  serous  in  character,  and 
its  sero-purulence  or  purulence  is  due  to  adventitious  causes,  such  as 
irritants  of  various  kinds.  There  is  every  reason  to  believe  that  much 
of  the  destructive  metamorphosis  of  chancres  is  engrafted  upon  them  by 
pyogenic  microbes.  Indeed,  in  many  instances  we  see  not  only  syphilitic 
infection  from  a  chancre,  but  also  pyogenic  infection.  The  immaturity 
of  the  newly  organized  cells  renders  their  existence  precarious,  and  in 
consequence  we  frequently  see  on  the  surface  of  chancres  molecular 
decay  or  gangrene.  This  form  of  decay  also  has  its  origin  in  the 
strangulation  of  the  capillaries  by  the  closely  packed  new  cells,  the 
result  of  which  is  necrosis  limited  to  the  parts  supplied.  This  strangu- 
lation of  the  vessels  is  an  important  factor  in  the  phagedena  which 
sometimes  attacks  hard  chancres. 

After  healing  and  absorption  the  chancre  usually  leaves  a  more 
or  less  well-developed  scar,  which  is  generally  depressed,  and  some- 
times it  is  nodular.  In  many  cases,  however,  no  trace  of  the  chancre 
is  left. 


PLATE   XXIX. 


FIG.  2. 


FIG.  3. 


FIG.  4. 


UNUSUAL  FORMS  OF  CHANCRE. 


Fig.  i. — Multiple  ecthymatous  chancres. 

Fig.  2.— Multiple  and  intrapreputial  chancres  and  specific  lymphangitis. 

Fig.  3. — The  beefsteak  chancre. 

Fig.  4. — Mixed  chancre. 


DESCRIPTION  OF  THE  CHANCRE. 


505 


GENERAL  DESCRIPTION  OF  THE  FULLY  DEVELOPED 
INDURATED  CHANCRE  IN  THE  MALE. 

A  study  of  the  following  figures  in  connection  with  the  description 
riven  in  the  text  will  convey  a  very  clear  idea  of  the  salient  features  of 

Fig.  125. 


Hard  chancre  of  the  balanopreputial  fold. 

hard  chancres  which  have  healed  and  have  become  true  indurated  nodules 
or  plaques  :     In  Fig.  125  a  well-developed  hard  chancre  of  the  mucous 

Fig.  126. 


More  salient  hard  chancre  of  the  balanopreputial  fold. 

membrane  of  the  balanopreputial  fold  is  well  shown,  while  in  Figs.  12(3 
and  127  more  pronounced  types  arc  strikingly  depicted. 

In  Fig.  128  a  large  plaque  of  induration  in  the  classical  site  for  penile 


506     THE  CHANCRE,    OR   THE  INITIAL   LESION  OF  SYPHILIS. 

hard  chancre,  namely,  on  the  mucosa  of  the  prepuce  beginning  on  the 
balanic  sulcus,  which  sometimes  causes  both  phimosis  and  paraphimosis, 
will  be  readily  recognized. 

The  tendency  of  the  hard  chancre  in  many  cases  to  develop  into  an 
annular  nodular  patch  is  well  shown  in  Fig.  129.  The  rather  infrequent 
development  of  the  hard  chancre  of  the  integument  of  the  penis  into  a 

Fig.  127. 


Very  extensive  hard  chancre  of  the  balanopreputial  fold. 

well-marked  indurated  nodule  or  plaque  is  portrayed  in  Fig.  130,  in 
which  the  initial  lesion  began  as  an  ecthymatous  chancre. 


DURATION  OF  THE  CHANCRE. 

The  duration  of  the  initial  lesion  of  syphilis  is  very  variable,  and 
depends  largely  upon  the  extent  and  density  of  the  new  growth.  In 
some  cases  it  is  so  slight  and  insignificant  that  it  comes  and  goes  with- 
out its  presence  having  been  known  or  without  leaving  a  trace.  This 
anomaly  is  sometimes  seen  in  women,  less  commonly  in  men.  The 
tissue  forming  the  primary  nodule,  being  of  unstable  nature,  is  pecu- 


DESCRIPTION  OF  THE  CHANCRE. 


507 


liarly  susceptible  to  the  action  of  mercury,  under  which  it  can  often  be 
seen,  as  it  were,  to  melt  away.  So  that  if  the  chancre,  as  it  often  does, 
exists  until  the  evolution  of  secondary  lesions,  it  usually  disappears  quite 
rapidly  under  the  influence  of  systematic  treatment.  But  in  some  cases 
it  is  very  voluminous  and  persistent,  and  may  exist  for  months.     Those 

Fig.  128. 


Large  plaque  or  nodule  in  typical  site,  with  two  as  yet  unhealed  chancrous  erosions. 


oft-quoted  cases  in  which  it  is  said  to  have  lasted  years  were  in  all 
probability  instances  of  fibroid  cicatrices  resulting  from  chancres.  I 
have  seen  many  of  these  which  had  been  regarded  as  persistent  and 
permanent  indurations,  whereas  the  syphilitic  neoplasm  had  vanished 
years  before  and  was  replaced  by  firm  fibrous  tissues. 


508      THE  CHANCRE,    OR   THE  INITIAL  LESION  OF  SYPHILIS. 


LOCATION  OF  THE  LESION. 

Chancres  of  the  Urethra. — Chancres  may  be  seated  on  one  or  on 
both  lips  of  the  meatus,  but  they  most  commonly  involve  the  circum- 
ference of  the  urethra.  In  some  cases  there  is  no  ulceration  of  any 
degree,  the  lips  of  the  meatus  being  scarcely  redder  than  normal, 
and  the  only  appreciable  morbid  process  being  the  condensation  and 
induration  of  the  parts.     Induration  here  is  usually  very  well  marked. 

Fig.  129. 


Nodular  annular  chancre  of  the  frcenum. 

Sometimes  one  lip  of  the  meatus  and  the  wall  of  the  urethra  feel  as  if 
formed  of  a  thin  plate  of  ivory.  This  same  condition  is  often  found  in 
both  lips.  Then,  again,  a  distinct,  hard  nodule  may  be  felt  at  the  distal 
end  of  the  urethra.  Chancres  at  the  meatus  may  be  of  the  form  of 
chancrous  erosions  or  they  may  present  the  typical  cream-green  tint, 
which  may  become  of  a  deep,  dull  green  or  even  of  a  greenish-black 
color.  A  diagnostic  mark  of  much  importance  in  this  form  of  chancre 
is  the  purplish-blue  color  of  the  glans  in  a  halo-like  form.  This  is 
well  shown  in  Fig.  8,  Plate  XXVIII. 


LOCATION   OF  THE  LESION. 


509 


Chancres  of  the  fosss  navicularis  and  of  the  deeper  parts  begin 
painlessly,  with  gluing  of  the  lips  of  the  meatus  as  their  first  symptom. 
Soon  there  is  slight  pain  as  the  urine  first  passes,  and  the  patient  dis- 


Fig.  130. 


Ecthyrnatous  chancre  of  integument  of  penis  with  much  induration. 

covers  a  thickening  of  the  tissues  at  the  site  of  the  chancre.  The  dis- 
charge is  sometimes  mucopurulent,  but  may  be  decidedly  purulent,  and 
as  considerable  in  quantity  as  in  ordinary  gonorrhoea.     This  is  due  to 


510      THE  CHANCRE,    OB    THE  INITIAL   LESION  OF  SYPHILIS. 

the  fact  that  the  lesion  sets  up  a  urethritis  of  the  contiguous  membrane. 
External  palpation  shows  that  the  corpus  spongiosum  is  converted 
into  a  hard,  tender,  circumscribed  nodule,  which  gives  pain  on  urina- 
tion and  on  erection  of  the  penis.  With  the  endoscope  we  observe 
rigidity  and  erosion  of  the  urethral  walls,  which  have  a  grayish-red 
color. 

Chancres  of  the  Scrotum. — In  somewhat  rare  cases  chancres  appear 
on  the  scrotum,  usually  on  its  anterior  or  lateral  portion,  rarely  on  the 
back  part. 

The  initial  lesion  in  this  locality  is,  as  a  rule,  of  goodly  size,  varying 
between  that  of  a  three-cent  silver  piece  and  that  of  a  quarter-dollar, 
sometimes  even  larger.  Two  varieties  of  lesion  are  commonly  met  with 
— the  chancrous  erosion  and  the  encrusted  chancre.  The  lesion  is  round 
or  oval,  somewhat  elevated,  having  a  smooth,  flat,  velvety  surface  when 
of  the  erosive  type,  and  being  somewhat  concave  or  saucer-shaped 
when  of  the  encrusted  type.  The  false  membrane  which  covers  scrotal 
chancres  is  of  the  grayish -green  color  already  described,  but  it  may 
become  yellowish  or  brown,  or  even  black.  (See  Plate  XXX., 
Fig.  5.) 

Chancres  of  the  Anus. — Chancres  are  found  beyond  the  anal  ring, 
at  its  margin,  and  within  the  ring  as  far  up  as  an  inch  and  perhaps 
farther.  These  lesions  in  this  location  do  not  usually  present  clearly  cut 
features.  Outside  the  anal  ring  they  may  be  oval  or  round  or  of  irreg- 
ular outline.  They  are  of  a  pale  rose,  sometimes  red,  color,  covered 
with  a  slimy  secretion,  and  perhaps  creased  or  fissured.  Within  the 
anal  ring  they  are  usually  found  to  consist  of  sluggish,  hardened 
fissures.  These  are,  however,  less  painful  than  simple  fissures — a  diag- 
nostic point  of  much  importance.  A  further  point  is  that  in  this  form 
of  chancre  there  is  marked  enlargement  of  the  inguinal  ganglia. 

Chancres  of  the  General  Integument. — Chancres  appearing  on 
parts  other  than  the  genital  organs  are  called  extragenital  chancres, 
and  are  mostly  found  on  the  face,  the  neck,  the  arms,  the  fingers,  the 
hypogastrium ;  in  fact,  they  may  be  found  on  any  part  of  the  body. 
They  begin  as  a  small,  dull-red  papule  with  more  or  less  scaliness, 
which,  if  situated  on  parts  in  coaptation  with  another  surface  of  integu- 
ment, becomes  a  chancrous  erosion,  and  in  that  form  runs  its  course. 
Usually  these  chancres  become  encrusted.  Chancres  of  the  general 
integument  run  a  chronic,  indolent,  painless  course,  and  may  last  many 
months  before  healing.  They  usually  give  rise  to  no  painful  symptoms, 
and  early  in  their  course  they  have  no  concomitant  phenomena  except 
the  painless  enlargement  of  the  lymphatic  ganglia  of  the  region  upon 
which  they  are  developed.  When  they  finally  undergo  resolution  they 
leave  pinkish,  brownish-red,  and  brownish-black  pigmented  spots,  with 


CHANCRES  OF  THE  FINGER.  511 

more  or  less  atrophy  and  cicatrization  of  the  skin,  which  last  for  a  long 
time. 

Chancres  of  the  Finger. — These  chancres  are  found  most  commonly 
among  surgeons,  obstetricians,  dentists,  midwives,  and  nurses,  male  and 
female.  In  these  individuals  the  infection  is  usually  contracted  in 
operations  either  upon  a  newly  made  cut  or  an  abrasion,  excoriation  of 
the  skin,  or  upon  some  simple  lesion  present  upon  the  skin,  as,  for 
instance,  eczema  and  dermatitis  due  to  the  use  of  antiseptics  and  irrita- 
tions. Among  the  laity  chancres  of  the  fingers  are  not  very  common, 
and  they  are  usually  the  result  of  libidinous  toying  with  the  genitals  of 
an  infected  woman.  Finger-chancres  also  sometimes  result  from  the 
bite  of  a  person  having  syphilitic  lesions  in  the  mouth,  and  they  have 
been  known  to  follow  a  blow  received  upon  the  mouth  of  a  person  suf- 
fering at  the  time  from  specific  lesions. 

The  Excoriated  or  Exulcerated  Nodule  or  Mass. — This  is 
the  most  common  form  of  chancre  of  the  finger.  It  is,  as  a  rule,  found 
near  the  tip  of  the  finger.  It  usually  begins  as  a  small  pustule,  a  minute 
excoriation,  or  as  a  fissure  or  hang-nail.  The  cell-growth  increases 
rapidly,  and  the  lesion  in  its  early  days  is  indolent  and  painless.  In  a 
few  weeks  the  chancre  becomes  fully  developed  into  a  large,  fleshy, 
smooth  or  granular,  or  even  lumpy  mass  of  dull-red  color,  sometimes 
with  a  purplish  tinge.  There  may  be  density  in  the  morbid  tissue,  but 
certainly  no  typical  induration.  Very  often  the  chancre  is  soft  and 
pulpy.  These  chancres,  being  exuberant  in  development,  produce  much 
deformity  in  the  parts  affected.  Their  shape  depends  on  the  site  upon 
which  they  are  developed.  They  are  sometimes  the  seat  of  severe  and 
continuous  pain. 

The  Fungating  Chancre. — This  form  of  finger-chancre  develops 
usually  on  the  pulp  of  the  organ  and  around  the  last  phalanx.  A  warty 
or  decidedly  papillomatous  mass,  sometimes  of  much  exuberance,  is  pro- 
duced, which  is  indolent  in  its  course  and  presents  sometimes  a  very 
deep-red  color,  and  not  uncommonly  a  purplish-red  color,  sometimes 
tinged  with  gray. 

The  Panaritium-like  Chancre. — This  chancre  usually  begins 
in  the  integument  of  the  nail-margin  in  a  cut  or  fissure  or  hang-nail  or 
some  inflammatory  lesion.  Soon  an  excoriated  spot  forms,  which  may  be 
localized  to  one  part  of  the  nail-margin,  or  this  latter  may  be  wholly  in- 
volved. When  fully  developed  we  find  an  encrusted  or  exulcerated  swell- 
ing of  more  or  less  extent.  The  surface  frequently  becomes  covered 
with  a  yellowish-green  or  dark-green  membrane,  and  the  thickening  of 
the  chancre  extends  to  the  parts  beyond.  This  lesion  is  frequently 
attended  with  severe  pain  during  its  verv  chronic  course.  (See  Plate 
XXX.,  Fig.  6.) 


512      THE  CHANCRE,    OR   THE  INITIAL   LESION  OF  SYPHILIS. 

Usually  the  epitrochlear  ganglion  in  anatomical  association  with  the 
affected  member  is  enlarged,  often  to  a  considerable  size,  varying  from 
that  of  a  nutmeg  or  that  of  a  pea  to  that  of  a  horse-chestnut.  Some- 
times there  is  no  perceptible  enlargement  of  the  epitrochlear  ganglia,  in 
which  event  those  of  the  axilla?  are  much  swollen.  There  is  usually 
swelling  of  the  axillary  ganglia  concomitant  to  that  of  the  epitrochlear 
ganglia. 

In  some  rare  cases  the  swellings  of  the  epitrochlear  and  axillary 
ganglia  go  on  to  suppuration. 

Cases  of  syphilitic  infection  of  patients  by  surgeons,  obstetricians, 
and  midwives  having  chancres  on  their  fingers  are  not  at  all  uncommon. 

In  some  rare  cases  chancres  of  the  finger  become  contaminated  with 
infectious  material  and  more  or  less  severe  pyseniia  or  septicemia  com- 
plicates the  case. 

The  scaling  papule  or  tubercle  is  the  rarest  of  all  forms  of  finger- 
chancre.  It  is  usually  found  on  the  dorsal  surface  of  a  phalanx,  and 
sometimes  on  the  sides  and  palmar  surface  of  the  fingers. 

Chancres  of  the  Lip. — Chancres  of  the  lip  are  quite  common. 
They  are  usually  seated  on  the  vermilion  border,  sometimes  on  the  inner 
border,  and  again  on  both  the  vermilion  border  and  the  skin.  They 
may  be  seated  on  the  cutaneous  portion  of  the  lip  alone.  These  chancres 
are  rarely  seen  early  in  their  course,  since  their  nature  is  frequently 
unrecognized  until  they  have  reached  full  development.  They  begin 
as  small  round  or  oval  excoriations  or  as  fissures,  and  are  at  first  looked 
upon  as'  cold  sores  or  cracks  of  the  lip. 

It  sometimes  happens  that  a  minute  excoriation  or  small  fissure  will 
run  a  very  ephemeral  course,  and  disappear  in  a  week  or  ten  days  with- 
out having  or  leaving  after  it  any  induration.  In  these  cases  the 
only  early  sign  of  syphilitic  infection  is  the  marked  enlargement  of 
the  submaxillary  and  sublingual  glands,  which  may  be  so  extensive  as 
to  constitute  a  temporary  deformity.  But  in  most  instances  chancre 
of  the  lip  goes  on  to  full  development,  producing  a  raw,  eroded,  flat 
plaque  or  nodule  whose  shape  is  in  conformity  with  the  arrangement  of 
the  parts,  or  an  encrusted  lesion  is  produced.     (See  Plate  XXX.,  Fig.  1.) 

Chancres  of  the  Tongue. — These  chancres  have  not  clearly  marked 
features.  They  appear  as  tolerably  well-circumscribed  nodules  either 
at  the  tip  or  on  the  lateral  portion.  Their  surfaces  are  red,  eroded, 
sometimes  covered  with  a  milky  pellicle,  frequently  uneven  and  trav- 
ersed by  minute  fissures.  Their  nodular  character,  chronic  indolent 
course,  and  external  features  point  to  their  nature.  The  submaxillary 
glandular  enlargement  aids  in  making  the  diagnosis.  It  must  be  re- 
membered that  cancer  of  the  tongue  begins  in  a  little  nodule,  perhaps 
warty  in  appearance,   and  is  soon  complicated  by  glandular   enlarge- 


PLATE   XXX. 


EXTRA-GENITAL    AND    UTERINE    CHANCRES. 


CHANCRES  OF  THE  EXTERNAL   EAR.  513 

ment.  In  persons  under  forty  or  fifty  years  it  will  generally  be 
found  that  the  tongue-lesion  is  of  syphilitic  origin.  In  middle  and 
advanced  age  the  probabilities  are  that  the  lesion  is  cancerous  rather 
than  syphilitic. 

Chancres  of  the  Gums  and  of  the  Hard  Palate. — These  lesions 
are  very  rare,  indeed,  and  several  cases  reported  as  such  were  un- 
doubtedly those  of  hypertrophic  mucous  patches.  The  surgeon  should 
be  cautious  before  pronouncing  as  chancre  localized  red  thickening  of 
the  mucous  membrane  of  these  parts.  When  present  these  chancres  are 
simply  hypertrophied  chancrous  erosions,  the  so-called  ulcus  elevatum. 
Owing  to  the  condition  of  the  parts,  it  is  difficult  to  determine  the  extent 
of  the  induration.  As  a  rule,  these  lesions  cause  little  trouble  and  are 
attended  with  scarcely  any  pain  when  unirritated.  When  seated  near 
the  margin  of  the  gums  they  may  be  attacked  by  ulceration. 

Chancres  of  the  Tonsil. — These  chancres  are  rather  common.  The 
frequency  to-day  of  the  tonsillar  chancre  is  due  to  the  fact  that  its 
existence  is  now  well  understood  and  surgeons  are  on  the  lookout  for  it. 

The  tonsillar  chancre  never  presents  a  definite,  typical  appearance, 
since  the  tissues  upon  which  it  is  seated  differ  in  each  individual.  What- 
ever may  have  been  the  conformation  of  the  parts,  whether  moderately 
smooth  or  more  or  less  anfractuous,  so  will  the  chancre-lesion  be  but  an 
exaggeration  of  that  condition,  due  to  hyperemia  and  hyperplasia  of  the 
parts.  Examination  is  difficult  in  all  cases,  particularly  so  in  some. 
When  accessible  to  the  finger-tip,  the  tonsil-chancre  will  feel  hard, 
brawny,  and  may  even  be  cartilaginous.  In  some  cases  the  new  growth 
is  tolerably  well  circumscribed  ;  in  others  it  is  quite  diffuse,  involving  a 
whole  tonsil  and  some  of  the  tissues  around  it.  The  surface  of  the 
chancre  may  be  simply  red  and  superficially  eroded  ;  it  may  be  covered 
with  a  milky-looking  membrane,  resembling  a  mucous  patch ;  or  a 
dull-green  membrane  of  considerable  firmness  may  cover  the  lesion. 

These  chancres  usually  become  troublesome  early  in  their  course. 
The  patients  complain  of  pain,  uneasiness,  and  of  difficulty  in  swallow- 
ing. Sometimes  the  suffering  is  very  great.  Then  the  submaxillary, 
sublingual,  and  lymphatic  ganglia  swell  up,  so  as  to  produce  large- 
sized  bunches  in  the  neck.  These  by  their  size  impede  motion  and 
deglutition  and  add  materially  to  the  patient's  suffering.  These  ganglia 
become  matted  into  hard,  firm,  indolent  masses.  In  some  cases  the  pre- 
auricular ganglia  are  enlarged. 

Chancres  of  the  External  Ear. — Chancres  of  the  ear  are  very  rare. 
The  parts  which  have  been  found  to  be  affected  are  as  follows  :  the 
auricle,  the  lobule,  the  integument  over  the  mastoid  process,  and  the 
base  of  the  tragus.  Chancres  of  the  ear  are  of  the  dry,  scaling,  erosive, 
or  encrusted  forms. 

33 


514      THE  CHANCRE,    OR   THE  INITIAL  LESION  OF  SYPHILIS. 

The  pharyngeal  orifice  of  the  Eustachian  tube  has  been  found  the 
seat  of  chancre  resulting  from  catheterization  by  means  of  instruments 
soiled  with  syphilitic  material. 

Chancres  of  the  Eyelids. — These  chancres  are  not  common,  al- 
though many  cases  are  reported  in  literature.  They  are  found  on  the 
free  margin  of  either  lid  or  the  adjacent  integument,  and  also  on  the 
inner  surface  of  the  palpebral  mucous  membrane.  They  are  usually 
of  the  erosive  type,  with  either  slight  or  decidedly  marked  induration, 
which,  however,  does  not  spread  much  around  the  original  lesion.  Fig. 
3  of  Plate  XXIX.  gives  a  very  clear  picture  of  these  palpebral  chancres. 
The  creamy-green  color  of  the  membrane  covering  the  chancre  is  well 
shown. 

Chancres  of  the  eyelids  are  always  accompanied  by  painless  hard 
enlargement  of  the  pre-auricular  ganglia,  and  generally  by  marked 
enlargement  of  the  cervical  ganglia  of  the  corresponding  side  of  the 
face. 

GENITAL  AND  EXTRAGENITAL  CHANCRES  IN  WOMEN. 

Chancres  of  the  genital  organs  are  very  common  in  women,  but 
extragenital  chancres  occur  in  them  much  more  frequently  than  they 
do  in  men. 

Chancres  in  women  are  usually  far  less  regular  in  their  course  than 
they  are  in  men.  In  many  women  the  chancre  is  so  small,  benign,  and 
ephemeral  that  it  may  never  be  seen,  or,  if  seen,  its  nature  is  usually 
not  suspected.  In  very  many  cases,  even  when  the  lesion  is  strikingly 
apparent,  its  nature  remains  for  a  long  time  in  doubt,  owing  to  inflam- 
matory complications  and  to  a  want  of  striking  individuality  in  the 
lesion  itself.  Then,  again,  simple  inflammatory  processes  and  chan- 
croidal ulcers  often  become  upon  the  female  genitals  so  hyperplastic  in 
appearance  that  they  may  resemble  specific  lesions.  In  women  indura- 
tion as  a  symptom  is  not  so  generally  observed  as  in  men.  In  some 
females  it  can  scarcely  be  appreciated  by  careful  examination,  and  it 
may  be  very  transitory  in  its  duration,  whereas  in  others  it  attains  large 
proportions,  lasts  for  indefinite  periods,  and  may  lead  to  ultimate 
deformity.  In  men  the  chancre  is  readily  examined.  In  women  this 
lesion,  owing  to  the  nature  and  inaccessibility  of  the  parts,  is  very  dif- 
ficult of  examination  except  on  protruding  portions  of  the  genitals. 

In  the  majority  of  cases  there  is  but  one  chancre,  but  in  fully  one- 
third  of  the  cases  the  lesion  is  multiple.  There  may  be  two  or  three, 
and  rarely  more  than  eight,  infecting  chancres  in  one  woman. 

The  main  reason  why  chancres  in  the  female  are  so  little  understood, 
are  so  frequently  unrecognized,  and  generally  offer  so  much  difficulty  in 


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GENITAL  AND  EXTRAGENITAL  CHANCRES  IN   WOMEN.       515 

diagnosis  is  that  there  is  little  opportunity  for  their  study  on  a  large 
scale. 

The  Chancrous  Erosion. — The  most  constant  early  appearance  of 
the  syphilitic  chancre  in  women  is  seen  in  the  form  of  an  erosion  of  the 
mucous  membrane.  In  its  very  early  days  this  lesion  presents  no  well- 
marked  characteristics,  and  is  very  liable  to  be  mistaken  for  a  ruptured 
herpetic  vesicle,  an  abrasion,  chafe,  or  scratch.  Such  is  its  seemingly 
benign,  superficial,  and  aphlegmasic  character  and  small  size  that  its 
nature  is  frequently  not  determined  at  the  first  examination.  (See  Plate 
XXXI.,  Figs.  1  and  3.) 

The  chancrous  erosion  is  always  found  on  the  surface  of  the  mucous 
membrane.  It  begins  as  a  red  spot,  somewhat  deeper  in  color  than  the 
mucous  surface  on  which  it  is  seated.  It  is  very  rarely,  if  ever,  seen 
in  women  during  the  first  few  days  of  its  existence,  for  the  reason  that 
its  presence  is  usually  unknown  to  its  bearer,  or,  if  it  is  seen  by  her, 
it  appears  so  harmless  that  its  nature  is  scarcely  ever  suspected. 

The  Scaling  Papule  or  Tubercle. — This  lesion  is  found  upon  the 
outer  surface  of  the  labia  majora ;  upon  the  labia  minora  when  they  are 
long  and  their  structure  resembles  that  of  the  integument ;  upon  the 
prepuce  of  the  clitoris  when  it  is  long  and  protrudes  from  the  vulva ; 
upon  the  internal  surface  of  the  thighs,  the  inguinal  folds,  and  the  bypo- 
gastrium.  It  begins  in  a  very  insignificant  manner  as  a  small,  dull-red 
papule,  which  may  be  scaly.  This  lesion  increases  circumferentially, 
but  usually  does  not  become  much  elevated.  As  it  grows  it  develops 
into  a  flat,  brownish-red  and  sometimes  purplish-brown,  perhaps  scaly, 
elevation  of  the  skin,  with  a  sharply  defined  margin. 

The  Elevated  Papule  or  Tubercle  (Ulcus  Elevatum).— This 
chancre  presents  the  appearance  of  a  circumscribed,  flat  or  elevated 
lesion  whose  surface  is  similar  to  that  of  the  chancrous  erosion. 
Indeed,  it  may  be  defined  as  a  chancrous  erosion  in  which  the  hyper- 
plastic process  has  been  very  active  and  productive  of  much  infiltration. 
Cases  not  infrequently  present  themselves  in  which  we  can  watch  the 
development  of  the  ulcus  elevatum  from  the  chancrous  erosion.  (See 
Fig.  2,  Plate  XXXI.) 

The  Incrusted  Chancre. — This  chancre  is  not  uncommonly  found 
upon  juxtapudendal  cutaneous  surfaces,  and  indeed  upon  any  portion  of 
the  integument.  It  has  been  stated  that  incrusted  chancres  are,  as  a 
rule,  not  found  within  the  area  of  the  mucous  membrane  of  the  vulva, 
but  that  their  habitat  is  the  tegumentary  structures.  It  is  true  that  in 
most  instances  vulvar  chancres  are  of  the  erosive  or  papulotubercular 
variety.  This  is  largely  due  to  the  fact  that  the  coaptation  of  the  parts 
and  their  moisture,  aided  very  often  by  pathological   secretions,  cause 


516      THE  CHANCRE,   OR   THE  INITIAL  LESION  OF  SYPHILIS. 

any  surface-covering  of  the  chancre  to  disappear.  (See  Plate  XXXII., 
Figs.  1  and  2.) 

The  Indurated  Nodule. — This  chancre,  so  common  in  men,  is  very 
rare  in  women.  In  men  the  syphilitic  neoplasm  or  nodule,  as  a  general 
rule,  becomes  circumscribed  into  a  little  mass  ;  in  women  this  new  growth 
tends  to  diffuse  itself  into  the  soft  mucous  tissues.  Thus  it  is  that  we 
rarely  see  the  indurated  nodule  in  the  female  sex,  except  on  parts  where 
the  skin  and  mucous  membranes  fuse.     (See  Plate  XXXII. ,  Fig.  3.) 

The  indurated  nodule  is  seen  as  a  sharply  circumscribed  mass  of 
indurated  tissue,  which  may  be  broad  and  flat,  or  it  may  have  a  narrow 
base,  sloping  edges,  and  flat  surface. 

Chancres  of  the  Vagina. — These  are  very  rare,  and  are  usually 
within  an  inch  of  the  vaginal  ring.  They  are  found  on  the  anterior 
and  posterior  walls  in  the  form  of  erosions  with  considerable  hardness 
or  in  the  incrusted  state.  Usually  there  is  but  one  chancre  ;  sometimes 
there  are  two. 

Chancres  of  the  Os  Uteri. — These  lesions  are  seated  either  on  the 
anterior  or  posterior  lip  of  the  uterus,  perhaps  more  frequently  on  the 
former  than  the  latter.  On  these  sites  they  may  extend  up  the  inner 
surface  of  a  lip,  even  into  the  uterine  cavity.  In  some  cases  the  chancre 
surrounds  the  os  and  involves  a  portion  of  the  inner  surface  of  the  lip. 
As  a  rule,  but  one  chancre  is  present ;  rarely  two  are  seen.  (See  Fig.  4, 
Plate  XXX.) 

Chancres  of  the  Breast. — Chancres  are  found  upon  the  female 
nipple,  upon  its  areola,  and  rarely  upon  the  integument  beyond  the 
areola. 

These  chancres  are  of  the  erosive  and  incrusted  types,  and  some- 
times they  exist  as  indurated  fissures. 

Upon  the  nipple  the  chancre  forms  a  flat  plaque  of  varying  size  or  a 
distinct  nodule  involving  part  or  all  of  the  appendage.  When  the 
woman  does  not  give  the  breast  to  her  child  the  chancre  shows  a  ten- 
dency to  become  incrusted,  but  during  nursing  moisture  keeps  the  parts 
in  an  eroded  condition. 

Chancres  very  commonly  form  in  the  furrow  at  the  base  of  the  nipple, 
and  then  they  assume  shapes  resembling  segments  of  circles,  and  some- 
times they  are  completely  circular  in  form.  These  chancres  are  most 
commonly  of  the  incrusted  variety. 

Chancres  of  the  areola  are  usually  small  round  or  oval  erosions, 
sometimes  flat,  again  elevated ;  or  they  may  be  saucer-shaped  and  slightly 
depressed  below  the  normal  plane.  Very  rarely  do  these  chancres 
become  incrusted.  In  this  situation  it  is  common  to  find  six  or  eight, 
or  even  as  many  as  sixteen,  of  these  chancres.  In  some  cases  the  lesions 
are  found  on  both  breasts. 


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RELAPSING  INDURATIONS.  517 

RELAPSING    INDURATIONS  (ALSO    CALLED    PSEUDO- 
CHANCRE   INDURE,    CHANCRE  REDUX). 

The  genital  organs  and  any  part  of  the  integument  or  mucous  mem- 
branes upon  which  the  initial  lesion  has  existed  may  at  any  time  in  the 
course  of  syphilis  be  the  seat  of  recurring  indurated  nodules,  which  are 
liable  to  be  mistaken  for  primary  lesion. 

There  are  two  kinds  of  these  relapsing  indurations — the  superficial  and 
the  deep.  The  superficial  induration  is  in  every  respect  like  a  true 
chancre,  consisting  of  a  localized  infiltration,  somewhat  elevated,  hav- 
ing a  smooth  exulcerated  surface  which  secretes  a  scanty  mucous  fluid. 
It  generally  appears  upon  the  mucous  layer  of  the  prepuce  or  upon  the 
glans  in  the  form  of  a  small  papule.  It  runs  an  indolent  course,  and 
may  attain  a  large  size.  It  may  be  accompanied  by  enlargement  of 
the  inguinal  ganglia  if  it  appear  within  the  first  and  second  years. 
It  sometimes  appears  exactly  on  the  seat  of  a  former  primary  lesion, 
and  is  generally  solitary.  It  may  also  develop  upon  a  herpetic  lesion, 
or  an  erosion,  or  a  fissure.  It  is  not  uncommonly  seen  as  a  localized 
thickening  of  mucous  membrane  the  surface  of  which  is  intact. 
These  superficial  relapsing  lesions  are  sometimes  very  rebellious  to 
treatment,  both  external  and  internal — a  feature  in  marked  contrast 
with  what  occurs  in  the  initial  lesion. 

These  superficial  relapsing  indurations  in  some  rare  cases  recur  from 
time  to  time  at  intervals  of  months  and  of  a  year  or  two. 

The  deep  relapsing  induration  occurs  in  the  submucous  connective 
tissue  of  the  prepuce  and  of  the  labia  majora.  It  consists  of  a  sharply 
defined  nodule  of  cartilaginous  hardness,  freely  movable,  and  generally 
not  adherent  to  the  mucous  membrane.  Its  growth  is  rapid,  and  it 
sometimes  reaches  the  size  of  a  nutmeg.  There  maybe  several  of  these 
tumors,  and  I  have  seen  five  in  one  case.  The  lesion  may  remain  inac- 
tive for  a  long  time,  causing  no  pain,  but  giving  some  inconvenience  in 
coitus.  In  some  cases  it  contracts  adhesions  with  the  surrounding  soft 
parts  ;  exceptionally,  it  undergoes  necrosis  and  forms  a  deep  ulcer  which 
is  difficult  to  cure.  In  women  the  infiltration  is  often  extensive,  in- 
volving, perhaps,  the  whole  labium.  The  induration  is  very  marked  and 
often  persists  for  years.  In  rare  cases  the  lips  and  labia  minora  are 
involved.  There  is  usually  no  enlargement  of  the  inguinal  ganglia  with 
the  deep  induration,  either  in  men  or  in  women. 

These  indurations  may  occur  as  early  as  the  first  and  as  late  as  the 
tenth  year  of  syphilis.  They  are  amenable  to  early  treatment,  but 
become  obstinate  with  age.  They  have  been  known  to  undergo  spontane- 
ous involution  and  to  relapse  after  complete  cure.  It  is  important  to 
distinguish  them  from  primary   lesions  of  syphilis.     Many  of  the  re- 


518      THE  CHANCRE,   OB   THE  INITIAL   LESION  OF  SYPHILIS. 

ported  eases  of  reinfection  have  no  doubt  been  examples  of  relapsing 
induration.  In  practice  these  relapsing  lesions  are  found  more  fre- 
quently in  men  than  in  women. 

TREATMENT  OF  CHANCRE. 

It  can  now  be  stated  with  positiveness  that  syphilis  cannot  be 
aborted  by  early  cauterization  or  excision  of  the  chancre  nor  by  the  re- 
moval of  the  inguinal  ganglia,  and  that  early  and  energetic  mercurial 
treatment  beginning  Avith  the  appearance  of  the  chancre  is  powerless 
to  prevent  infection  of  the  system. 

When  seen  at  a  very  early  date  upon  the  male  genitals  the  chancre 
usually  appears  as  a  minute  round  or  oval  excoriation  or  as  a  papule 
with  a  scaly  or  oozing  surface.  So  much  does  this,  the  earliest  of  all 
evidences  of  syphilis,  resemble  simple  benign  lesions  that  mistakes  are 
very  liable  to  occur,  and  a  chancre  may  be  diagnosticated  as  an  excoria- 
tion, an  abrasion,  or  as  a  simple  inflammatory  papule,  or  vice  versa. 
Under  these  circumstances  the  physician  cannot  be  too  careful  and 
guarded  in  the  diagnosis  of  any  seemingly  insignificant  lesion  upon  the 
penis.  It  is  well  to  warn  a  patient  not  to  indulge  in  sexual  intercourse 
for  at  least  two  weeks,  by  which  time  the  nature  of  the  lesion  will  be 
beyond  question,  since  if  it  is  benign  it  will  commonly  heal  under  simple 
treatment  and  cleanliness,  and  if  it  is  an  incipient  hard  chancre  its 
evolution  will  continue  and  its  appearance  will  indicate  its  character. 
It  is  of  the  utmost  importance  that  no  stimulating  or  escharotic  appli- 
cations should  be  made  to  these  small  lesions  for  very  good  and  suffi- 
cient reasons.  In  the  first  place,  if  the  lesion  is  simple  in  nature,  burn- 
ing it  with  acid  or  other  caustic  will  not  destroy  it,  but  simply  transform 
it  into  an  inflammatory  nodule,  which  may  present  a  striking  resem- 
blance to  a  young  hard  chancre,  and  thus  doubt  and  uncertainty  of 
mind  are  induced  or  an  error  in  diagnosis  is  the  result.  If  the  lesion 
is  an  incipient  chancre,  it  is  a  localized  specific  neoplasm,  which  cauter- 
ization, however  severe,  cannot  possibly  destroy,  but  it  can  cause 
a  complicating  oedema  which  may  be  troublesome  to  cure.  It  may  be 
stated  as  a  golden  rule  that  we  must  not  lay  violent  hands  on  these 
seemingly  simple  and  perhaps  insignificant  lesions.  Any  breach  of 
surface,  therefore,  should  be  kept  scrupulously  clean  by  washing,  and 
its  surface  covered  with  lint  or  absorbent  cotton  moistened  with  boiled 
or  distilled  water.  In  many  cases  a  water  dressing  is  sufficient,  but 
mild  sublimate  solutions  (1  :  1000,  2000,  or  3000)  may  be  applied,  or 
very  dilute  solutions  of  carbolic  acid.  These  applications  may  be 
made  every  two,  three,  or  four  hours.  Peroxide  of  hydrogen  (1  part) 
and  water  (6  parts)  make  a  solution  which  will  produce  an  antiseptic 
effect.     As  the  hard  chancre  grows  larger  it  mav  be  treated  with  black 


TREATMENT  OF  CHANCRE.  519 

wash  or  with  yellow  wash.  It  must  be  understood  that  the  therapeu- 
tical effect  of  these  lotions  is  simply  protective  and  slightly  stimulating. 
They  prevent  irritation  and  ulceration  by  keeping  the  parts  clean  and 
aseptic.  The  chancre  offers  a  nidus  for  pus-producing  microbes,  and 
when  it  is  not  large  antiseptic  washes  are  all  that  is  required  in  the  way 
of  treatment. 

Chancres  covered  with  a  false  membrane,  thick  or  thin,  those  which 
show  a  tendency  to  become  necrotic  upon  their  surfaces  or  in  which  a 
decided  tendency  to  ulceration  is  seen,  may  not  be  sufficiently  influenced 
by  the  foregoing  applications.  In  these  cases  it  is  important  that  a 
decidedly  caustic  effect  should  be  produced.  In  cauterizing  hard,  as 
well  as  soft,  chancres,  carelessness  and  recklessness  must  be  carefully 
avoided.  The  lesion  to  be  treated  should  first  be  carefully  washed 
with  soap  and  water,  and  then  irrigated  with  a  5  per  cent,  carbolic 
solution.  It  should  be  dried  and  a  solution  of  cocaine  applied  to  it, 
and  then  it  should  be  dried  again.  A  more  expeditious  preparatory 
method  is  to  sop  the  surface  of  the  lesion  freely  with  peroxide  of  hydro- 
gen diluted  with  an  equal  quantity  of  water,  then  to  dry  the  surface 
and  apply  the  cocaine,  and  again  dry  the  parts.  As  a  routine  applica- 
tion nothing  is  better  than  fluid  carbolic  acid  or  pure  nitric  acid.  These 
agents  should  be  sparingly,  carefully,  and  not  frequently  applied  to  the 
surface  of  the  sore,  and  not  beyond  it.  A  small  quantity  of  cotton 
rolled  on  the  end  of  a  wooden  toothpick  offers  the  most  effective  and 
satisfactory  means  of  application.  Calomel  very  often  acts  promptly 
and  effectively  upon  chancres  which  show  a  destructive  tendency.  It 
is  also  useful  as  a  dry  dressing  on  clean  but  indolent  chancres.  It  is 
well  to  bear  the  fact  in  mind  that  this  destructive  treatment  is  only  in- 
dicated in  cases  in  which  the  surface  of  the  sores  is  unhealthy  and  shows 
no  tendency  to  heal.  After  cauterization  it  is  necessary  to  apply  anti- 
septic remedies  in  the  powder  form.  It  is  always  imperative  that  these 
lesions  should  be  carefully  washed  twice  a  day,  and  the  patient  should 
be  warned  to  destroy,  preferably  by  fire,  all  linen  used  in  the  cleansing, 
and  to  be  careful  not  to  touch  with  soiled  fingers  any  article  which 
others  may  handle. 

The  efficient  powders  for  use  are  aristol,  europhen,  antinosine,  noso- 
phen,  and  acetanilid.  Dermatol  may  be  of  benefit  in  some  cases.  Some 
chancres  in  both  men  and  women  fail  to  respond  to  the  remedies  just 
mentioned,  and  then  we  are  forced  to  resort  to  the  one  remedy — iodo- 
form— which  rarely  is  found  wanting. 

New  remedies  come  and  go,  but  this  one  stays  by  us.  It  may  be 
said  without  fear  of  contradiction  that  for  the  dressing  of  ulcers  and 
wounds  about  the  genitals,  male  and  female,  there  is  no  remedy  so 
efficient  or  which  has  such  a  wide  range  of  usefulness.     Its  odor  is  of 


520      THE  CHANCRE,    OR   THE  INITIAL  LESION   OF  SYPHILIS. 

course,  objectionable,  but  with  care  much  of  this  inconvenience  may  be 
obviated.  In  the  first  place,  the  powder  must  be  very  carefully  and 
sparingly  put  on  the  surface,  and  not  allowed  to  fall  on  sound  parts 
or  upon  the  clothes.  Then,  if  the  lesion  is  under  the  prepuce,  the  odor 
may  be  kept  at  a  minimum  by  packing  cotton  in  the  preputial  orifice. 
If  the  lesion  is  on  an  uncovered  part,  it  should  be  enveloped  in  absorb- 
ent cotton  and  then  covered  with  gutta-percha  tissue.  A  little  care 
and  ingenuity  will  do  much  to  dissipate  a  patient's  disinclination  or 
repugnance  to  the  use  of  this  drug.  Though  many  drugs  have  been 
recommended  as  having  the  power  of  deodorizing  or  disguising  the  odor 
of  iodoform,  none,  in  my  judgment,  has  proved  successful.  By  far 
the  best  deodorant  is  cumarin,  which  in  small  quantities  may  be  added 
to  iodoform.  It  must  always  be  remembered  that  this  powder  is  ap- 
plicable only  to  unhealthy  and  necrotic  surfaces,  and  that  when  a  smooth 
healing  surface  has  been  produced  its  use  must  be  discontinued  and  one 
of  the  simple  stimulating  or  antiseptic  lotions  or  powders  should  be 
substituted. 

Such  is  the  satisfactory  action  of  some  of  the  new  antiseptics  men- 
tioned that  the  use  of  black  or  yellow  wash  is  becoming  less  frequent. 
These  remedies  will  certainly  clear  up  the  ulcerated  surface  of  many 
chancres,  but  it  is  always  best,  if  we  can,  to  produce  this  result  with  dry 
dressings. 

It  must  not  be  forgotten  that  the  main  benefit  of  all  antiseptic  rem- 
edies for  chancre  consists  in  their  power  of  preventing  ulceration,  and 
by  this  means  they  hasten  the  cure.  It  is  important,  however,  that  a 
specific  action  should  be  brought  to  bear  on  all  chancres  which  show  a 
tendency  to  become  indurated.  Having  by  the  proper  means  produced 
a  healthy  surface,  the  chancre  should  be  treated  with  mercurial  oint- 
ment. The  surface  having  been  washed  and  rendered  as  nearlv  as 
possible  aseptic,  a  layer  of  absorbent  cotton  or  lint  well  smeared  with 
this  ointment  should  be  placed  upon  it,  and  kept  in  constant  apposition. 
It  is  important  that  the  dressing  should  be  renewed  two  or  three  times 
a  day. 

Chancres  in  women  require  the  same  general  treatment  as  for 
those  in  men.  In  many  cases  they  run  their  course  and  disappear 
without  treatment  and  perhaps  without  recognition.  In  some  cases, 
however,  they  are  obstinate  and  persistent,  and  require  time  and  care 
for  their  removal.  It  is  always  imperative  that  the  vagina  and  vulva 
should  be  kept  particularly  clean  in  women  having  syphilitic  chancres. 
They  should  use  frequent  irrigations  of  hot  water  to  which  borax,  alum, 
sulphate  of  zinc,  or  carbolic  acid  is  added.  Then  the  parts  should  be 
kept  as  dry  as  possible,  for  which  purpose  tampons  of  absorbent  cotton 
are  very  effective.    In  some  cases  extensive  and  troublesome  indurating 


TREATMENT  OF  CHANCRE.  521 

oedema  becomes  a  complication  of  the  vulvar  chancre,  and  its  presence 
means  a  long  siege  of  annoyance  and  perhaps  suffering.  When  possible, 
chancres  in  the  female  should  be  dressed  with  mercurial  ointment  in 
the  manner  described  above.  If  the  induration  is  extensive  or  if  it 
shows  a  tendency  to  spread,  it  is  well  to  cover  the  chancre  and  a  liberal 
area  of  the  parts  around  it  with  the  ointment.  In  some  cases  a  strong 
calomel  or  white-precipitate  ointment  may  be  used  in  place  of  the 
mercurial  ointment.  In  some  ulcerative  cases  aristol  and  iodoform  may 
be  required.  It  is  well  also  to  use  the  other  antiseptic  powders  already 
mentioned,  since  they  may  be  of  use  in  women. 


CHAPTER  XXIX. 

PEIMARY   SYPHILIS. 
LYMPHANGITIS   AND   ADENITIS. 

Induration  of  the  Lymphatics. 

Though  for  brevity,  and  largely  on  account  of  its  general  acceptance, 
I  use  the  above  term,  it  is  well  to  remember  that  in  syphilis  the  chancre 
is  first  formed,  and  from  this  focus  the  infection  promptly  travels  up  the 
perivascular  lymph-spaces  which  surround  the  vessels.  Therefore,  to 
be  strictly  and  scientifically  accurate,  this  condition  is  a  syphilitic  hyper- 
plasia of  the  perivascular  lymph-spaces,  a  periphlebitis,  and  a  peri- 
arteritis. 

Specific  enlargement  of  the  lymphatics  is  characterized  by  three 
important  symptoms — viz.,  induration,  absence  of  inflammation,  and 
persistency. 

The  indurated  vessel  feels  like  a  hard  cord  running  from  the  neigh- 
borhood of  the  chancre  toward  the  pubes  along  the  upper  surface  of  the 
penis  in  the  course  of  the  dorsal  vein  and  artery,  or,  in  a  few  instances, 
it  occupies  the  side  of  this  organ.  It  is  generally  single,  but  sometimes 
multiple  ;  of  the  size  of  a  crow-quill  or  goose-quill ;  in  some  cases  of  uni- 
form diameter,  when  it  communicates  to  the  fingers  a  sensation  like  that 
of  the  vas  deferens,  while  in  others  it  is  swollen  at  regular  intervals  like 
a  necklace,  or  is,  as  botanists  wrould  say,  moniliform.  The  distal  ex- 
tremity arises  in  the  induration  surrounding  the  chancre,  and  the  cord 
can  generally  be  traced  for  two  or  three  inches  toward  the  pubes,  some- 
times to  the  base  of  this  prominence,  but  rarely  as  far  as  the  indurated 
ganglia  in  the  groin. 

Induration  of  the  lymphatics  appears  about  the  same  time  and  in  the 
same  manner  as  that  of  the  base  of  the  chancre,  and  the  two  generally 
correspond  in  degree  of  development.  The  former  is  less  constant  than 
the  latter,  but  if  sought  for  may  be  found  in  a  large  proportion  of  cases. 

Induration  of  the  lymphatics  usually  undergoes  resolution  about  the 
same  time  as  that  of  the  chancre,  but  in  a  few  instances  it  becomes 
inflamed  and  terminates  in  suppuration,  when  fistulous  openings  may 
form  along  the  course  of  the  vessel.  In  these  cases  there  is  usually  a 
complicating  infection  of  the  chancre  by  pus-microbes,  and  an  active 
suppurating  process  results  which  spreads  to  the  lymph-spaces. 

It  is  always  well  to  cause  patients  to  rub  mercurial  ointment  into 

522 


ADENITIS.  523 

hyperplastic  syphilitic  lymphatics  and  ganglia  as  soon  as  general  mani- 
festations show  themselves.  Such  a  course  materially  aids  in  curing 
the  syphilis.  In  case  the  lymphatics  are  swollen,  lint  smeared  with 
mercurial  ointment  should  be  wrapped  around  the  penis  and  kept  there 
night  and  day  if  practicable. 

Adenitis. 

In  every  case  of  hard  chancre  the  neighboring  ganglia  become  indo- 
lently enlarged,  and  in  many  instances  the  lymphatic  vessels  are  involved 
in  a  similar  change.  The  enlargement  is  sometimes  appreciable  as  early 
as  the  fifth  day  after  the  appearance  of  the  sore,  and,  as  a  rule,  between 
the  seventh  and  the  tenth  days.  In  rather  exceptional  cases  well-marked 
induration  may  not  be  felt  until  the  fourteenth  day,  rarely  later.  At 
first,  it  is  usually  more  pronounced  on  the  same  side  as  the  chancre. 
Later  on,  both  sides  are  involved,  though  the  enlargement  is  sometimes 
unilateral.  The  hardness  of  the  ganglia  is  peculiar  in  its  density  and 
painlessness.  They  are  freely  movable,  and  feel  under  the  skin  like 
almonds  or  little  round  tumors,  which  do  not  usually  adhere  to  one 
another  or  to  the  overlying  integument.  Sometimes  one  ganglion 
becomes  much  larger  than  the  rest,  and  exceptionally  a  number  become 
blended  into  an  indolent  mass.  In  somewhat  rare  cases  one  ganglion 
in  a  chain  seems  to  be  spared ;  thus  in  chancres  of  the  finger  the  epi- 
trochlear  may  not  be  appreciably  enlarged,  while  the  axillary  ganglia 
may  be  much  swollen. 

It  will  generally  be  found  that  those  ganglia  in  immediate  anatomical 
relation  with  the  seat  of  the  chancre  are  usually  the  ones  which  are  most 
swollen.  Induration  of  the  inguinal  ganglia  may  affect  one  or  both 
sides.  In  the  former  case  it  is  usually  the  side  upon  which  the  chancre 
itself  is  situated,  although  occasionally  this  rule  is  reversed,  as  with 
buboes  attendant  upon  a  chancroid. 

Wherever,  as  in  the  groin,  a  number  of  ganglia  form  a  group,  most 
of  them,  at  least,  are  usually  involved,  but  to  an  unequal  extent.  A 
"  pleiad,"  as  it  has  been  called,  or  a  rosary-like  arrangement,  of  small 
olive-shaped  or  globular  tumors,  is  felt,  cartilaginous  in  hardness,  freely 
movable  upon  each  other  and  the  surrounding  tissues,  and  without 
attachment  to  the  overlying  integument.  One  is  commonly  developed 
more  than  the  rest,  and  attains  about  the  size  of  an  almond ;  the  others, 
as  large  as  a  bean  or  cherry,  surround  it  like  satellites. 

There  are  no  symptoms  of  acute  inflammation.  The  change  has 
taken  place  insidiously  and  often  without  the  patient  knowing  it.  The 
skin  is  not  altered  either  in  color  or  temperature.  Firm  pressure  some- 
times reveals  slight  tenderness,  but  rarely  excites  severe  pain,  and  motion 
is  usually  not  impeded. 


524  PRIMARY  SYPHILIS. 

Less  frequently,  only  a  single  tumor  is  felt  in  the  groin,  varying  in 
size  and  shape  in  different  cases  :  sometimes  it  may  be  compared  to  a 
good-sized  plum,  while  at  other  times  it  is  elongated,  about  the  thick- 
ness of  the  finger,  and  corresponds  in  direction  to  the  inguinal  fold.  In 
some  instances  as  the  tumor  subsides  it  resolves  itself  into  several,  show- 
ing that  it  was  composed  of  a  number  of  coherent  ganglia  held  together 
by  a  mildly  proliferative  peri-adenitis. 

When  a  chancre  is  situated  at  a  distance  from  any  group  of  ganglia, 
as  upon  the  fingers  or  face,  only  one  or  two  of  these  bodies  are  usually 
involved. 

Induration  of  the  ganglia  usually  reaches  its  full  development  in  the 
course  of  a  week  or  fortnight. 

These  swellings  are  sometimes  called  syphilitic  buboes. 

Diagnosis. — In  general,  the  diagnosis  of  syphilitic  adenitis  is  easy 
when  this  condition  is  studied  in  connection  with  the  chancre.  It  is 
sometimes  observed  that  a  man  has  a  sore  of  doubtful  appearance  and 
with  unsatisfactory  history,  and  in  connection  therewith  there  is  indolent 
enlargement  of  the  inguinal  ganglia,  perhaps  bilateral,  which  the  patient 
claims  has  been  present  for  years.  In  such  instances  a  prompt  diagnosis 
cannot  be  made,  but  in  the  course  of  a  week  or  two  the  nature  of  the 
affection  can  be  determined. 

In  some  corpulent  subjects  it  is  often  very  difficult  to  make  out  clearly 
the  condition  of  the  inguinal  ganglia.  This  same  result  may  also  be  ob- 
served in  some  rare  cases  in  which  the  fascia  and  connective  tissues  are 
so  compact  and  unyielding  that  thorough  palpation  cannot  be  practised. 

In  forming  estimates  of  the  condition  of  the  inguinal  ganglia  it  is 
always  well  to  remember  that  other  morbid  conditions  besides  syphilis 
may  cause  them  to  become  indolently  swollen.  Thus,  after  the  sub- 
sidence of  gonorrheal  adenitis  the  ganglia  may  remain  hard,  firm,  and 
more  or  less  enlarged.  Eczema,  psoriasis,  phtheriasis,  and  all  inflam- 
matory diseases  of  the  skin,  when  they  attack  the  legs  lead  to  painless 
or  painful  enlargement  of  the  inguinal  ganglia. 

Resolution  without  suppuration  is  almost  the  constant  termination 
of  syphilitic  induration  of  the  ganglia.  When,  however,  the  chancre 
has  been  attacked  by  pyogenic  microbes — and  this  is  more  common 
when  phimosis  has  been  produced — a  suppurative  adenitis  sometimes 
results,  which  may  be  chronic  or  may  be  very  acute  and  present  the 
same  features  as  chancroidal  bubo.  It  is  not  uncommon  in  suppurating 
syphilitic  adenitis  in  the  groin  to  find  a  diffuse  bed  of  suppuration  in 
which  are  scattered  many  hyperplastic  and  much-swollen  ganglia. 

Treatment. — Mercurial  ointment  should  be  well  rubbed  into  the 
skin  over  the  hyperplastic  ganglia  every  day.  The  same  treatment  is 
necessary  for  the  lymphangitis. 


HYPERPLASIA    OF  LYMPHATIC  GANGLIA.  525 

Generalized  Hyperplasia  of  the  Superficial  and  Deep  Lymphatic 

Ganglia. 

With  the  generalization  of  the  syphilitic  infection  the  superficial  and 
deep  lymphatic  ganglia  of  the  whole  body  become  indolently  and  pain- 
lessly swollen.  Though  this  condition  is  spoken  of  as  essentially  be- 
longing to  the  secondary  period,  there  is  no  doubt  that  the  tissue- 
changes  which  take  place  in  the  ganglia  begin  quite  early  in  the 
secondary  period  of  incubation,  and  they  become  mature  at  the  time 
of  onset  of  other  secondary  lesions.  The  ganglia  which  are  most 
accessible,  and  therefore  important  in  a  diagnostic  point  of  view,  are 
the  anterior  and  posterior  cervical  ganglia,  situated  anteriorly  and  pos- 
teriorly to  the  sternocleidomastoid  muscle,  the  occipital  ganglia,  those 
over  the  clavicle  (on  either  end),  and  on  the  margin  of  the  pectoral 
muscles,  the  anterior  and  posterior  auricular  or  the  mastoid  ganglia,  the 
epitrochlear  at  the  elbow-joint  above  the  internal  condyle,  and  the 
axillary  ganglia.  All  of  these  ganglia  become  swollen  in  secondary 
syphilis  as  a  result  of  the  essential  hyperplastic  process  produced  by 
the  virus.  In  some  cases  the  ganglionic  reaction  is  rendered  more 
intense  by  the  presence  of  irritated  syphilitic  lesions  or  by  inflam- 
matory skin-lesions  which  may  be  developed  on  the  regions  of  the 
body  in  which  lymphatic  radicals  take  their  origin. 

In  this  way  the  lymphatic  ganglia  of  the  neck,  of  the  axillae,  and 
groin  may  become  acutely  swollen,  and  may  then  be  the  seat  of  pain. 
Whenever  any  of  these  ganglia  go  on  to  suppuration  it  is  certain  that  a 
nearby  pus-focus  has  supplied  the  irritating  secretions  or  the  microbes. 

While  hyperplasia  of  the  superficial  ganglia  occurs,  as  a  rule,  in 
early  secondary  syphilis,  this  condition  also  may  be  observed  in  ex- 
ceptional cases  in  late  syphilis,  particularly  in  persons  whose  nutrition 
has  been  lowered  and  whose  constitutions  have  been  impaired. 

It  is  now  generally  conceded  that  the  changes  in  the  deep  lymphatic 
ganglia  are  among  the  most  frequent  and  most  constant  of  the  effects  of 
tertiary  syphilis.  They  bear  the  same  relation  to  syphilis  of  the  viscera 
that  adenopathy  of  the  subcutaneous  lymphatic  glands  does  to  syphilis 
of  the  skin  ;  in  other  words,  they  are  its  constant  accompaniment.  The 
affection  of  the  deep  lymphatic  glands  may,  however,  exist  without  any 
lesion  of  the  viscera,  just  as  the  post-cervical  and  epitrochlear  glands 
may  be  enlarged  without  an  eruption  upon  the  scalp  or  arms. 

The  glands  most  frequently  affected  are  the  prevertebral,  lumbar, 
iliac,  and  femoral ;  the  mesenteric  glands  and  those  of  the  extremities 
are  rarely  involved.  The  changes  are  various.  Most  frequently  there 
is  hyperplasia  of  the  glandular  elements  ;  the  gland  is  increased  in 
length  rather  than  in  breadth,  is  friable,  of  soft  consistency,  of  a  red- 


526  PRIMARY  SYPHILIS. 

dish-  or  yellowish-gray  color,  its  surface  injected,  and  its  substance 
cheesy.  In  other  cases  the  connective  tissue  of  the  gland  appears  to 
be  the  chief  seat  of  the  lesion,  and  becomes  indurated.  Suppuration  is 
never  present,  which  is  an  important  diagnostic  sign  between  this  and 
the  affections  of  the  glands  in  typhoid  fever  and  in  tuberculosis. 

In  the  tertiary  stage  of  syphilis  the  ganglia  may  become  swollen  and 
the  seat  of  sclerosis  or  gummatous  induration.  The  affection  is  very 
chronic. 


CHAPTER   XXX. 

SECONDARY  SYPHILIS. 

SYMPTOMS  AND  AFFECTIONS  OF  THE  SECONDARY  STAGE. 

At  the  expiration  of  the  secondary  period  of  incubation,  which  may 
be  as  short  as  forty-five  days,  and  exceptionally  as  long  as  ninety 
(rarely  longer)  days,  the  secondary  period  of  syphilis  begins.  This 
stage  of  the  disease  is  also  called  the  period  of  general  or  constitutional 
manifestations,  and  also  the  condylomatous  stage.  The  teachings  of 
pathological  anatomy  show  very  clearly  that  in  the  secondary  period  of 
incubation  the  infection  of  the  whole  system  is  going  on  slowly,  insidi- 
ously, but  effectively,  until  in  the  end  the  acme  is  reached,  when  gen- 
eral systemic  manifestations  and  symptoms  are  developed. 

There  is  a  remarkable  variation  in  the  amount  of  systemic  disturbance 
at  the  beginning  of  the  secondary  period.  In  many  subjects  no  devia- 
tion whatever  from  the  healthy  standard  is  observed  to  mark  the  com- 
mencement of  the  secondary  stage,  and  the  dermal  lesions  are  the  only 
evidences  of  syphilis.  These  very  often  pass  away  unobserved,  and  as  a 
result  a  hiatus  in  the  patient's  medical  history  is  produced.  In  other 
cases,  however,  particularly  in  women,  much  and  varied  constitutional 
disturbance  takes  place.  In  some  cases  syphilis  comes  on  abruptly,  and, 
we  may  say,  it  explodes. 

Perhaps  the  most  constant  morbid  symptom  is  fever,  which,  though 
absent  in  many  cases,  is  present  in  most  in  varying  degrees  of  intensity. 
In  some  cases  there  is  an  elevation  of  temperature  of  from  one  to  three 
degrees,  commonly  with  a  corresponding  mild  nocturnal  exacerbation. 
In  other  cases  the  febrile  movement  is  well  marked,  the  morning  tem- 
perature being  from  101°  to  102°  F.,  and  in  the  evening  104°  F., 
and  in  rather  exceptional  instances  higher,  even  to  107°  F.,  particu- 
larly in  women.  Besides  the  elevation  of  temperature  there  is  a  corre- 
sponding acceleration  of  the  pulse,  and  the  respiration  ratio  is  increased. 
The  tissue-metamorphoses  are  present  in  proportion  to  the  intensity  of 
the  fever. 

Syphilitic  fever  not  infrequently  presents  a  distinctly  remittent  tvpe 
— a  peculiarity  which  may  be  noticed  in  the  early  period,  but  is  generally 
not  observed  until  late  in  the  course  of  syphilis.  In  some  rare  cases  of 
tertiary  syphilis  a  well-marked  febrile  condition  has  been  observed.  It 
is  in  such  cases  that  the  incorrect  diagnosis  of  tuberculosis  may  be  made. 

527 


528  SECONDARY  SYPHILIS. 

Various  neuralgic  pains  are  also  complained  of  by  patients,  the  peculi- 
arity of  which  is  their  constant  occurrence  toward  evening  and  at  night. 
Headache  is  mostly  nocturnal  in  character,  and  varies  from  a  mild  form 
to  one  in  which  the  patient's  sufferings  are  agonizing,  in  which  he  or 
she  is  tortured  by  pain  during  the  night,  and  prostrate,  worn  out,  and 
suffering  during  the  day,  when  the  pain  may  not  wholly  cease.  Such 
patients  say  that  their  heads  feel  as  if  they  were  being  crushed  as  by  a 
vise,  or  as  if  a  nail  were  driven  into  their  skulls.  Sometimes  the  pain 
seems  to  be  superficial,  and  may  affect  the  temporal,  frontal,  or  occipital 
regions.  In  other  cases  these  pains  are  so  excruciating  that  the  sufferer 
is  an  object  of  pity.  These  pains  in  the  head  may  occur  at  the  date 
of  onset  of  general  manifestations  and  at  later  periods. 

Intense  neuralgic  pains  affecting  the  cranial  nerves,  the  fifth  in  par- 
ticular, also  seated  in  the  intercostal  nerves,  in  the  sciatic  and  its  branches, 
and  in  the  anterior  crural,  are  not  uncommon.  Persons,  who  have  previ- 
ously suffered  from  neuralgia  of  any  part  are  especially  liable  to  exacer- 
bations during  the  eruptive  stage  of  syphilis,  and,  in  fact,  at  any  time 
during  the  activity  of  the  diathesis. 

Insomnia  is  a  symptom  sometimes  complained  of  by  syphilitic  patients, 
who  can  give  no  reason  for  it  whatever,  since  in  many  cases  there  is  no 
physical  suffering.  It  is  peculiar  in  the  fact  that  it  is  not  readily  influ- 
enced by  soporifics,  but  gradnally  ceases  with  the  disappearance  of  the 
exanthematic  symptoms  under  mercurial  treatment. 

Disturbances  of  the  sympathetic  nervous  system  are  sometimes 
strongly  marked,  particularly  in  ansemic  and  thin  persons  and  in  women. 
Such  patients  complain  of  cold  feet,  and  their  hands  feel  like  marble 
or  ice,  and  they  are  chilled  by  the  slightest  draft. 

Cachexia. 

At  certain  periods  during  its  course  syphilis  produces  an  adynamic 
condition  of  the  system  called  "  syphilitic  cachexia."  These  periods  are 
at  or  just  before  the  evolution  of  the  disease  during  the  secondary  stage 
and  toward  the  close  of  the  tertiary  stage. 

In  these  cases  there  may  be  observed,  soon  after  the  onset  of  the 
secondary  stage,  loss  of  appetite  and  strength,  emaciation,  and  a  pale, 
sallow  appearance.  The  pulse  becomes  rapid,  weak,  and  small,  and  the 
temperature  rises.  The  patient  feels  dejected,  nervous,  and  apprehensive. 
The  condition  becomes  graver  in  proportion  to  the  extent  of  the  numer- 
ous functional  disorders  which  accompany  the  inauguration  of  the 
secondary  stage. 

The  cachexia  of  the  secondary  period  of  syphilis  also  may  begin  a 
few  months  after  the  onset  of  the  disease.  It  is  seen  in  weakly  persons 
oftener  than   in  the  robust,  and,  again,  more  frequently  in   those  who 


THE   TYPHOWAL   CONDITION.  529 

have  had  imperfect  or  no  treatment  whatever ;  hence  we  have  reason 
to  infer  that  early  and  adequate  treatment  will  prevent  its  occurrence. 
The  general  symptoms  of  cachexia,  already  given,  are  repeated  in  this 
stage  of  syphilis  in  a  milder  form.  Frequently  nothing  can  be  found 
to  account  for  the  condition,  and  the  only  suspicious  feature  of  the  case 
is  the  occurrence  of  headache  or  pain,  which  is  more  severe  at  night. 
In  some  cases  neurasthenia  is  developed. 

The  Typhoidal  Condition. 

In  the  early  months  of  syphilis  certain  grave  adynamic  conditions 
sometimes  supervene,  which  may  very  properly  be  termed  the  syphilitic 
typhoidal  state.  This  condition,  which  is  not  common,  is  usually  seen  in 
weakly  and  overworked  or  under-fed  individuals,  and  in  males  more  fre- 
quently than  in  females.  Malaria  and  a  neuropathic  tendency  are  some- 
times contributory  causes.  It  may  occur  quite  early  in  the  infection 
coincidently  with  the  development  of  the  general  manifestations,  and  at 
any  time  during  the  first  year.  It  may  supervene  in  some  subjects  in 
whom  the  treatment  has  been  inefficient  or  wanting,  and  also  as  a  result 
of  excesses  (sexual  and  alcoholic),  and  of  severe  bodily  and  mental  strain. 

The  patient  may  or  may  not  complain  of  headache  at  first,  but  he 
experiences  a  feeling  of  great  weakness  which  soon  develops  into  utter 
prostration.  He  has  a  mild  continuous  fever  and  dull  frontal  headache, 
and  his  pulse  is  rapid  and  small.  He  becomes  pale  and  sallow,  has  no 
energy,  and  desires  to  lie  down.  All  his  senses  grow  to  be  impaired 
and  dull,  and  he  becomes  somnolent  and  torpid.  He  has  confusion  of 
thought,  vertigo,  and  sometimes  photophobia.  His  appetite  leaves  him, 
and  his  bowels  are  usually  slow  ;  exceptionally  there  is  diarrhoea.  In 
this  condition  he  will  lie  in  bed  indifferent  to  all  around  him,  not  caring 
for  food,  and  sometimes  having  great  distaste  for  it.  In  this  lethargic 
condition  he  may  become  mildly  or  severely  delirious,  and  in  some 
cases  maniacal.  It  will  be  observed,  however,  as  a  rule,  that  the  pecu- 
liar dull,  earthy  tint  of  the  face  so  constantly  seen  in  typhoidal  patients 
is  not  well  marked  in  syphilitic  subjects.  But  there  is  the  same 
typhoidal  facies,  as  shown  in  the  utter  loss  of  tone  of  the  facial  muscles. 

Though  the  condition  is  serious,  it  does  not  commonly  cause  death, 
and  it  may  be  relieved  by  antisyphilitic  treatment,  together  with  care 
and  nursing  and  nutritious  food.  The  convalescence,  however,  is  rather 
slow,  and  several  months  may  elapse  before  the  patient  begins  to 
gain  in  weight  and  acquires  his  normal  physical  strength  and  mental 
balance.  In  this  condition,  however,  hemiplegia,  aphasia,  and  epilepsy 
may  supervene,  and  then  the  gravity  of  the  case  is  much  increased. 

The  diagnosis  of  this  condition  is  usually  easy  if  the  medical  history 
of  the  patient  is  known.  The  absence  of  diarrhoea,  of  abdominal  ten- 
34 


530  SECONDARY  SYPHILIS. 

derness,  and  of  gurgling  in  the  right  iliac  fossa,  and  of  the  typically 
pronounced  typhoidal  facies,  will,  when  carefully  studied,  lead  the 
physician  to  a  correct  interpretation  of  the  nature  of  the  case. 

Hysteria. 

In  men,  and  particularly  in  women,  a  condition  of  pronounced  hys- 
teria may  be  developed  in  the  early  months  of  syphilis.  This  condi- 
tion may  be  comprehensively  portrayed  by  the  recital  of  the  following 
case,  which  brings  out  its  salient  features  :  After  the  onset  and  cessation 
of  roseolar  and  papular  eruptions,  rheumatoid  pains,  and  iritis,  a 
woman,  twenty-two  years  old,  began  to  suffer  from  continuous  supra- 
orbital pain  and  dizziness.  Her  gait  became  unsteady,  and  on  occasions 
a  sensation  as  if  she  would  inevitably  fall  backward  was  felt,  but  was 
always  controlled  by  a  forced  mental  effort.  She  was  emaciated,  and, 
instead  of  being  cheerful,  as  she  was  naturally,  she  was  sad  and  despond- 
ent. Her  appetite  was  poor,  but  not  capricious ;  the  bowels  moved 
regularly,  and  urine  was  normal  in  quantity  and  as  to  constituents,  and 
her  menses  were  regular.  Her  pulse  was  60  and  small,  and  the  tem- 
perature normal.  It  was  noticed  that  she  was  more  irascible  than  usual, 
and  after  such  spells,  which  were  of  frequent  occurrence,  she  often  wept 
copiously.  Then  she  would  remain  for  hours  in  a  condition  of  abstrac- 
tion, not  appearing  sensible  or  cognizant  of  her  surroundings.  She 
would  go  away  from  the  table  when  eating,  imagining  that  she  was  not 
good  enough  to  be  in  company  with  others.  At  other  times  she  would 
become  very  suspicious,  and  would  imagine  that  her  friends  were  con- 
spiring against  her  or  that  they  were  laughing  at  her  and  making  sport 
of  her.  Under  this  impression  she  would  become  very  nervous,  and 
would  shrink  away  and  cry,  and  would  perhaps  sit  for  hours  without  mov- 
ing ;  and  if  any  one  came  near  her  she  would,  as  it  were,  awaken  from 
her  lethargy  greatly  frightened  and  be  much  agitated.  When  spoken 
to  she  recognized  those  around  her  very  readily,  and  was  pleased  to  see 
them,  and  she  said  she  felt  a  queer  sensation  in  the  head.  "When  asked 
if  she  felt  badly  continuously,  she  replied  that  there  were  intervals  in 
which  she  was  comparatively  free  from  the  sensations,  and  that  she 
tried  very  hard  to  resist  them.  She  said  she  felt  quite  weak,  that  her 
memory  was  very  poor  in  comparison  to  what  it  had  been,  and  that  in 
reading  a  book  or  paper  she  often  forgot  what  she  had  read  when  she 
got  through.  This  fact  was  very  apparent,  for  she  was  fond  of  reading 
the  sensational  serials  in  the  weekly  papers,  but  her  memory  was  so 
much  impaired  that  she  could  not  keep  the  thread  of  the  narrative. 
She  complained  of  dimness  of  vision,  and  she  frequently  saw  muscce 
volitantes  before  her  eyes.  She  said,  also,  that  her  sleep  was  very  much 
disturbed,  and  she  frequently  awoke  greatly  alarmed.     Upon  walking 


SYNOVITIS.  531 

a  sensation  of  ataxia  was  noticed,  and  she  said  she  felt  uncertain  as  to 
where  she  was  placing  her  feet.  At  this  time  she  had  nocturnal  rheu- 
matoid pains  along  the  tibife  and  in  the  larger  joints. 

Analgesia. 

Syphilis  very  commonly  gives  rise  to  various  disorders  of  the  general 
seusibility,  especially  in  women.  The  most  frequent  of  these  is  a  loss 
of  the  perception  of  pain,  or  analgesia,  with  which  is  sometimes  com- 
bined absence  of  the  sense  of  touch  and  of  temperature.  In  such 
cases,  for  instance,  a  pin  may  be  thrust  deeply  into  the  flesh  without 
the  patient's  suffering  pain,  and  she  may  be  also  insensible  to  the  touch 
of  the  fingers,  or  cannot  distinguish  between  hot  and  cold  objects. 

Syphilitic  analgesia  varies  in  degree  in  different  cases,  and  also  in 
the  extent  of  the  surface  affected.  In  some  instances  it  extends  from 
head  to  foot,  in  others  it  is  confined  to  particular  regions,  when  the 
extremities  of  the  limbs,  as  the  hands,  the  lower  half  of  the  forearms, 
the  feet  and  ankles,  the  female  breasts,  are  almost  invariably  involved. 
The  back  of  the  hand,  over  the  dorsal  surface  of  the  metacarpus,  is  a 
favorite  site,  where  it  is  likely  to  be  found  if  anywhere.  The  disorder 
occurs  during  the  early  secondary  period,  and  most  commonly  lasts  for 
several  months. 

Disturbance  in  the  Reflexes. 

In  some  cases  of  syphilis,  prior  to  the  onset  of  general  manifesta- 
tions and  during  their  evolution,  an  exaggeration  of  the  reflexes  of  the 
skin  and  tendons  may  be  observed.  This  condition  may  develop 
slowly  or  it  may  appear  quite  suddenly.  Exceptionally  this  symptom 
is  found  in  the  late  stage  of  syphilis  in  cases  which  have  been  im- 
properly treated. 

Synovitis. 

Two  forms  of  synovitis  occur  during  the  course  of  syphilis — the  one 
simply  a  chronic  effusion  into  the  joint  without  appreciable  change 
therein  ;  the  other,  an  affection  in  which  there  is,  besides  the  effusion,  a 
thickening  of  the  synovial  membrane. 

Synovitis  begins  slowy  and  painlessly.  The  patient  experiences  slight 
stiffness  in  the  joint,  which  is  found  to  be  swollen.  On  examination 
the  usual  symptoms  of  effusion  are  found,  which  vary  according  to  the 
joint  attacked.  The  skin  covering  the  joint  is  not  changed.  Firm 
pressure  may  cause  slight  pain,  and  dull  pain  may  often  be  felt  at 
night,  but  the  articular  surfaces  may  be  crowded  together  with  impunity. 
The  amount  of  effused  fluid  varies;  in  some  cases  it  is  very  slight,  in 
others  copious.  A  peculiar  feature  of  this  affection  is  the  intermittent 
character  of  the  effusion.     In   some  cases,  particularly  those  who  are 


532  SECONDARY  SYPHILIS. 

subjected  to  treatment,  it  passes  slowly  away,  and  the  joint  is  apparently 
left  in  normal  condition. 

In  other  cases  the  affection  is  chronic  and  persistent,  and  the  effusion 
disappears  very  slowly.  In  these  cases  we  usually  find  the  whole  joint 
enlarged  and  indurated,  and  subject  to  frequent  small  effusions.  There 
is  no  tendency  to  suppuration  or  destruction  of  the  joint. 

Precocious  Osseous  Affections. 

The  bones  may  be  attacked  in  the  early  months  of  syphilis,  although 
osseous  lesions  generally  develop  quite  late.  The  bones  most  liable  to 
early  affection  are  those  of  the  cranium,  the  ribs,  the  sternum,  the 
clavicle,  and  the  tibia. 

Of  the  skull-bones,  the  frontal  and  parietal  are  most  commonly 
attacked.  The  swellings  vary  in  diameter  from  half  an  inch  to  an  inch 
and  a  half,  and  reach  a  height  of  half  an  inch.  They  are  round  and 
smooth,  and  if  slowly  developed  are  quite  hard.  They  may  be  single 
or  multiple,  unilateral  or  symmetrical.  They  may  occur  at  the  angle 
of  junction  of  the  frontal  bone  with  the  orbital  plates  or  on  the  occip- 
ital bone,  but  they  are  usually  on  the  sides  of  the  skull. 

The  clavicle  is  usually  affected  at  its  external  extremity,  the  artic- 
ulation sometimes  being  involved.  The  upper  third  of  the  sternum 
is  more  commonly  involved  than  the  lower  third.  Occasionally  its 
borders  are  attacked  with  portions  of  the  costal  cartilages,  when  the 
patient  may  complain  of  severe  dyspnoea  and  pain  on  deep  inspiration. 
In  such  a  case  a  localized  pleurisy  has  probably  been  excited.  In 
severe  cases  the  ribs  themselves  may  be  invaded,  especially  their  ante- 
rior portions.  Its  subcutaneous  surface  is  the  portion  of  the  tibia  most 
frequently  the  seat  of  these  tumors.  They  vary  in  size  and  number, 
but  are  usually  not  as  salient  as  similar  swellings  of  other  bones. 
The  radius  and  the  ulna  are  also  sometimes  attacked.  The  swellings 
are  usually  near  the  joint,  the  wrist  more  commonly  than  the  elbow. 

These  tumors  may  develop  rapidly  and  are  usually  the  seat  of  noc- 
turnal pain. 

Rheumatoid  Pains  and  Rheumatism. 

Some  of  the  most  constant  symptoms  in  the  early  months  of  syphi- 
litic infection  are  pains  in  the  muscles,  fascia?,  bones,  and  joints. 
These  are  termed  rheumatoid  pains,  articular  pains,  and  arthralgia  ; 
they  chiefly  attack  the  larger  joints,  such  as  the  shoulder,  the  knee,  the 
hip,  the  ankle,  elbow,  and  wrist,  and  often  the  phalanges.  The  muscles 
affected  are  chiefly  those  of  the  extremities,  and  the  fasciae  of  these 
parts  and  of  the  large  joints  are  also  attacked.  Sometimes  a  single 
muscle,  and  again  groups  of  muscles,  may  be  involved.     The  sensation 


PLEURISY.  533 

may  be  that  of  weakness  or  fatigue,  of  moderate  soreness,  and  even  of  a 
dull  or  severe  aching  pain.  The  pains  begin  generally  toward  even- 
ing, and  they  may  become  atrocious,  and  even  intolerable,  during  the 
night.  Toward  morning  they  usually  cease,  and  leave  a  sensation  of 
soreness  and  stiffness  in  the  joint. 

Acute  Articular  Rheumatism. 

As  a  very  exceptional  feature  in  secondary  syphilis  a  condition  re- 
sembling acute  articular  rheumatism  is  developed,  particularly  within 
the  early  months  of  the  infection.  The  joints  chiefly  attacked  are  the 
large  ones,  and  also  the  small  ones,  which  become  swollen  and  very 
painful,  and  the  skin  over  them  coincidently  becomes  red  and  tender. 
As  a  rule,  the  process  extends  over  several  weeks,  and  even  two  or 
three  months.  Usually  one  or  more  joints  are  attacked  at  a  time,  and 
whenever  the  inflammation  begins  it  shows  a  tendency  to  stay.  It  is 
not  common  in  acute  syphilitic  rheumatism  to  see  the  inflammatory 
process  cease  in  one  joint  and  then  jump  to  another,  as  it  so  commonly 
does  in  the  simple  form.  In  specific  rheumatism  heart-complications 
are  exceptional. 

The  fever  may  be  mild,  but  it  is  sometimes  of  quite  pronounced 
type.  There  may  be  mild  sweating,  but  we  do  not  observe  the  drench- 
ing sour  sweat  of  acute  rheumatism.  In  the  syphilitic  form  of  acute 
rheumatism  there  also  may  be  sometimes  observed  periosteal  swellings 
on  the  shafts  of  some  of  the  long  bones,  the  tibia,  fibula,  and  radius  and 
ulna  chiefly. 

Hyperaemia  and  Hyperplasia  of  the  Pharynx  and  Tonsils. 

In  many  cases  of  syphilis,  coincidently  with  the  evolution  of  the 
secondary  manifestation,  a  diffuse  redness  and  thickening  of  the  pharynx 
and  a  swelling  of  the  tonsils  may  be  seen.  Very  often  patients  are 
unaware  of  the  existence  of  this  local  trouble.  Then,  again,  the  sore- 
ness, stiffness,  and  pain  give  rise  to  much  suffering  and  inconvenience. 
In  many  of  these  cases  there  is  no  superficial  lesion  other  than  moderate 
excoriation  ;  in  some,  however,  mucous  patches  and  condylomata  may 
be  present.  This  pharyngeal  hyperaemia  may  be  very  persistent,  par- 
ticularly in  smokers,  and  in  some  patients  it  is  much  increased  by  the 
use  of  mercury  internally.  Local  treatment  is  very  important  for  this 
condition,  which  should  be  constantly  looked  for. 

Pleurisy. 

Recent  observations  have  conclusively  shown  that  the  pleura  may  be 
attacked  early  and  late  in  the  secondary  period  of  syphilis.  The  affec- 
tion may  or  may  not  have  distinctive  characteristics.     In  some  cases 


534  SECONDARY  SYPHILIS. 

patients  complain  of  pain  in  the  chest-wall,  which  is  usually  limited  to 
a  space  the  size  of  one  or  two  palms  of  the  hand.  It  is  not  uncommon 
in  dispensaries,  and  even  in  private  practice,  for  patients  to  present 
themselves  covered  with  an  erythematous  or  papular  rash,  and  for  the 
surgeon  to  find  one  or  more  porous  plasters  on  the  chest-wall,  usually 
about  midway  from  the  shoulders,  and  on  either  the  anterior  lateral  or 
posterior  surface.  They  may  complain  of  soreness,  stiffness,  or  even 
pain  of  a  dull  and,  somewhat  rarely,  stabbing  character.  In  these  cases 
there  may  be  no  fever,  or  the  temperature  may  be  a  little  above  the 
normal.  There  may  be  slight  effusion ;  rarely  is  it  copious.  In 
some  cases  a  mild  friction-sound  gives  evidence  of  moderate  fibrinous 
exudation. 

Angina  Pectoris. 

This  condition,  with  all  its  classical  symptoms,  is  in  rare  cases  seen 
in  secondary  and  tertiary  syphilis.  It  is  of  paroxysmal  occurrence,  and 
both  mild  and  severe  in  its  course,  and  sometimes  accompanied  by  ab- 
normal sensations  of  heat  and  cold  or  sweating  on  the  left  side  of  the 
body.     It  usually  yields  promptly  to  antisyphilitic  treatment. 

The  early  angina  pectoris  is  probably  due  to  irritative  lesions  in  the 
coronary  arteries,  and  perhaps  in  the  cardiac  plexus ;  the  late  form  gen- 
erally results  from  gummatous  formations  in  the  heart. 

Hyperemia  and  Hyperplasia  of  the  Spleen. 

With  the  evolution  of  secondary  manifestations  and  symptoms,  par- 
ticularly in  cases  of  anaemia  and  cachexia,  in  which  the  condition  of  the 
blood  is  much  deteriorated,  there  will  sometimes  be  found  decided 
swelling  of  the  spleen.  The  patients  complain  of  a  dull,  heavy  sensa- 
tion in  the  splenic  region,  and  in  some  cases  a  mild  or  severe  pleuritic 
pain  may  be  felt.  This  condition  is  usually  ephemeral,  and  slowly 
subsides  under  antisyphilitic  treatment  and  when  the  general  nutrition 
improves. 

Jaundice. 

In  early  secondary  syphilis  and  during  the  first  year  of  the  infection 
there  is  not  infrequently  seen  a  mild  and  ephemeral  form  of  jaundice. 
This  evidence  of  hepatic  derangement  may  consist  simply  of  moderate 
yellowness  of  the  skin  of  the  face,  or  there  may  be  a  dense  golden- 
yellow  discoloration.  In  case  of  jaundice  there  is  usually  chloro-ana?mia 
or  asthenia. 

This  condition  is  probably  due  to  an  irritative  process  acting  upon 
the  common  bile-ducts,  and  not  to  any  structural  lesion. 

The  jaundice  of  secondary  syphilis   may  last  only  a  few  weeks,  but 


HEMORRHAGE.  535 

in   severe  cases,  particularly  when   treatment  has  not  been  adopted,  it 
may  last  two  or  three  months. 

Albuminuria  and  Ephemeral  Nephritis. 

There  can  no  longer  be  a  doubt  that  early  and  sometimes  rather  late 
in  the  secondary  stage  a  mild  or  more  severe  form  of  nephritis  may 
occur. 

It  is  believed  by  several  authors  that  the  early  or  precocious  nephritis 
of  syphilis  has  the  characteristics  of  the  same  condition  due  to  other 
infectious  fevers  and  diseases,  and  that  it  is  a  glomerulonephritis  com- 
parable to  that  of  scarlatina.  Some  authors  claim  that  mercurial  treat- 
ment causes  the  kidney-changes  ;  but  we  have  no  definite  knowledge  on 
the  subject. 

The  symptoms  of  early  renal  syphilis  may  be  wanting,  and  the  dis- 
eased condition  may  only  be  discovered  upon  examination  of  the  urine. 
Then,  again,  in  some  cases  there  is  oedema  of  the  lower  extremities  and 
of  the  face,  and  perhaps  there  may  be  moderate  or  extensive  pleural 
or  abdominal  effusion. 

In  many  cases  this  nephritis  is  curable  by  antisyphilitic  treatment, 
aided  by  care  as  to  regimen  and  the  use  of  a  milk  diet.  In  some  cases, 
particularly  in  patients  who  indulge  in  an  excess  of  alcoholic  liquors 
and  who  are  exposed  to  cold,  parenchymatous  changes  are  produced. 

The  ephemeral  nephritis  of  secondary  syphilis  is  to  be  feared,  for  the 
reason  that  it  may  lead  to  structural  changes  in  the  kidneys. 

Temporary  glycosuria  and  peptonuria  have  been  recognized  in  some 
rare  cases  of  secondary  syphilis. 

Hemorrhage. 

Any  of  the  secondary  eruptions  of  syphilis  may  be  accompanied  by 
hemorrhagic  effusion,  either  around  or  into  the  substance  of  the  lesion. 
It  may  occur  on  the  lower  extremities  of  those  whose  general  health  is 
unimpaired,  and  is  then  not  of  serious  import,  or  it  may  occur  on  various 
other  portions  of  the  body  of  broken-down  and  scorbutic  persons.  In 
all  of  these  cases  the  effusion  is  secondary  to  the  specific  process, 
spontaneous  transudation  of  blood  into  the  skin  of  syphilitics  being  a 
rare  occurrence. 

The  etiological  relation  between  syphilis  and  hemoglobinuria  has  not 
as  yet  been  clearly  made  out,  but  there  is  distinct  evidence  that  syphilis 
acts  as  a  causative  factor  in  this  peculiar  form  of  blood-degeneration. 


CHAPTER   XXXI. 

SECONDARY  ERUPTIONS,  OR  SYPHILIDES. 

The  early  eruptions  of  the  secondary  stage  are  distributed  symmetri- 
cally and  generally  over  the  body,  involving  the  superficial  layers  of  the 
skin ;  the  later  lesions  of  this  stage,  although  extensively  and  symmetric- 
ally spread,  are  less  copious,  and  show  a  tendency  to  localization,  and, 
moreover,  invade  deeper  portions  of  the  skin.  The  lesions  of  the  ter- 
tiary stage  are  always  profound  and  are  less  profusely  distributed,  but 
they  involve  more  extensive  portions  of  particular  regions  for  which 
they  seem  to  have  a  predilection,  and  they  are  frequently  unsymmet- 
rical.  The  course  of  the  tertiary  lesions  is  decidedly  more  prolonged 
and  indolent  than  that  of  the  secondary. 

Their  course,  as  compared  with  that  of  simple  eruptions,  is  marked 
by  chronicity  and  absence  of  inflammatory  features.  They  may  be 
accompanied  by  a  moderate  degree  of  systemic  reaction.  In  some 
erythematous  and  papular  syphilides  of  the  early  period  of  syphilis  the 
intensity  of  this  reaction  and  the  active  character  of  the  eruption  may 
render,  the  diagnosis  from  one  of  the  simple  exanthems  very  difficult. 
The  actual  nature  of  the  eruption  is  demonstrated  by  its  quickly  assum- 
ing a  subacute  course.  With  the  progress  of  the  syphilis  the  tendency 
of  the  eruptions  to  present  a  chronic,  apyretic  character  is  more  marked. 
Some  local  exciting  cause  may  usually  be  found  for  the  hyperemia  and 
inflammation  sometimes  attending  tubercular,  ulcerative,  and  gummatous 
syphilides. 

In  strict  accuracy  the  only  purely  syphilitic  skin  lesions  are  those 
produced  by  erythema  and  cell-changes — namely,  the  erythematous  and 
pigmentary,  and  the  papular,  tubercular,  and  gummatous  syphilides,  in 
which,  when  uncomplicated,  there  is  no  suppuration.  These  dermal 
affections  result  directly,  without  complication,  from  specific  syphilitic 
process.  The  various  pustular  syphilides  of  the  secondary  stage  and  the 
rupial,  ulcerative,  and  serpiginous  syphilides  of  the  later  stage  are  really 
the  results  of  mixed  processes  or  infections.  In  these  cases,  in  some 
occult  manner,  the  hyperemia  and  hyperplasia  of  syphilis  become  com- 
plicated by  the  action  of  pyogenic  microbes.  Many  so-called  syphilitic 
lesions — namely,  the  impetigoform  and  the  ecthymatous  syphilides — 
very  often  present  an  exceedingly  striking  clinical  picture  of  microbic 
invasion  of  an  integument  which  seems  susceptible  to  their  influence, 
536 


SECONDARY  ERUPTIONS,    OR  SYPHILIDES.  537 

and  in  which  the  resulting  low-grade  pyogenic  process  seems  to  lux- 
uriate.    (See  Plate  VI.) 

Absence  of  Itching  and  Pain. — Owing  to  their  indolent  nature  syph- 
ilitic eruptions  do  not,  as  a  rule,  cause  any  irritation  of  the  skin. 

Itching  may  be  present  in  connection  with  an  early  eruption  whose 
evolution  is  particularly  acute.  It  is  never  so  intense  as  in  a  simple 
eruption,  and  is  much  more  ephemeral.  It  is  perhaps  more  troublesome 
with  an  eruption  occurring  on  the  scalp  than  elsewhere,  and  when  com- 
plicating an  early  rash  it  is  generally  limited 'to  the  extremities,  the 
upper  more  often  than  the  lower. 

Polymorphism. — The  simultaneous  occurrence  of  several  varieties  of 
lesions  in  the  same  eruption  is  an  important  and  common  feature  of 
syphilis.  It  is  due  to  three  causes :  the  chronic  course  of  syphilides, 
their  relapsing  tendency,  and  the  changes  occurring  in  the  lesions. 
Polymorphism  is  most  frequently  observed  early  in  the  secondary  stage, 
since  eruptions  are  then  more  numerous;  yet  it  may  exist  even  with  the 
late  tubercular  eruptions. 

Color  and  Pigmentation. — It  is  important  to  distinguish  the  color  of 
the  syphilides  from  the  pigmentation  which  frequently  follows  them. 
Their  usual  tint  is  pinkish  red,  being  much  more  subdued  than  that  of 
simple  eruptions.  Even  in  exceptional  cases  of  acute  invasion,  in  which 
the  color  may  be  unusually  bright,  it  is  less  intense  than  in  the  simple 
exanthemata.  The  hue  soon  fades  to  a  brownish  one,  which  after  invo- 
lution of  the  eruption  changes  to  a  copper-colored,  yellowish-brown 
maculation.  Pressure  dissipates  the  color  during  the  early  stages  of  an 
eruption,  but  finally  the  pigmentation,  which  has  been  compared  to 
"the  lean  of  ham,"  to  the  color  of  copper,  and  to  a  combination  of  yel- 
low and  brown,  becomes  permanent. 

These  pigmentary  changes  are  not  peculiar  to  syphilis,  being  equally 
well  marked  in  lichen  planus  and  in  cases  of  protracted  dermatitis. 
They  are  probably  due  to  deposit  of  coloring-matter  of  the  blood  in  the 
affected  spots. 

Tendency  to  Assume  a  Circular  Form. — The  early  eruptions  are  gen- 
erally distributed  over  the  surface  without  definite  order,  except  in  some 
instances  in  particular  regions,  where  they  may  be  arranged  in  a  circular 
manner.  This  peculiarity  is  more  commonly  seen  in  the  case  of  small 
papular  rashes  and  in  the  erythematous  syphilide.  The  latter  often 
relapses  in  the  shape  of  distinctly  marked  rings,  differing  from  the 
papular  syphilide,  in  which  the  bases  of  the  papules  generally  merge 
and  form  wavy  lines  or  segments  of  circles  or  perhaps  complete  circles. 
In  certain  large  papules  and  in  some  papulotubercles  involution  begins 
at  their  centres,  and  the  periphery  is  left  in  a  ringed  form. 

The  Influence  of  Intercurrent  Diseases  on  the  Course  of  Syphilides. — 


538  SECONDARY  ERUPTIONS,    OR  SYPHILIDES. 

The  course  of  syphilitic  eruptions  is  not  infrequently  interrupted,  or 
even  permanently  arrested,  by  some  acute  disease.  Numerous  instances 
have  been  reported  of  the  disappearance  of  an  eruption  at  the  outset  of 
an  inflammatory  affection  of  the  lungs,  of  acute  articular  rheumatism, 
of  various  adynamic  fevers,  and  of  acute  cerebral  disease. 

During  an  attack  of  erysipelas  secondary  and  tertiary  syphilides 
have  been  observed  to  undergo  involution ;  not  only  were  the  lesions  in 
the  area  of  the  acute  exanthem  affected,  but  also  those  seated  at  a  dis- 
tance from  it  disappeared. 

This  healing  action  of  erysipelas  on  syphilitic  neoplasms  is  undoubt- 
edly due  to  the  changes  produced  in  the  tissues  by  the  Loeffler  bacillus 
or  its  toxins. 

Unusual  3fodes  of  Evolution. — The  appearance  of  a  generalized 
eruption  is  looked  upon  as  the  indication  of  constitutional  infection,  but 
the  first  eruption  may  be  limited,  and  a  general  rash  may  not  be  devel- 
oped for  several  weeks.  In  some  cases  only  two  or  three  dermal  lesions 
can  be  found  at  the  usual  date  of  invasion.  Should  the  eruption  be 
erythematous,  the  spots  soon  become  coppery,  and  remain  in  a  chronic 
condition  ;  if  papular,  the  papules  are  sluggish,  and  usually  leave  a 
pigmented  spot.  In  connection  with  these  precocious  lesions  the  patient 
may  suffer  from  syphilitic  pains  in  the  head,  in  the  bones,  etc.,  and 
perhaps  may  have  erythema  of  the  fauces  and  high  temperature. 
Within  two  to  six  weeks  the  general  eruption  follows. 

The  Localization  of  the  Syphilides. — Syphilitic  eruptions  are  often  found 
in  regions  where  simple  skin  lesions  are  seldom  or  never  developed. 

Secondary  eruptions  appear  on  the  scalp,  and  especially  at  its 
margin  on  the  forehead,  at  the  angles  of  the  mouth,  on  the  alse  of  the 
nose,  about  the  anus  and  upon  the  genitals,  near  the  umbilicus,  in  the 
inguinal  folds,  between  the  toes,  and  upon  the  palms  and  soles.  The 
supraclavicular  and  infraclavicular  and  sternal  regions,  where  non- 
specific and  parasitic  eruptions  are  often  found,  are  rarely  the  seat  of 
specific  exanthems,  and  on  the  dorsum  of  the  hands  the  latter  are  not 
often  seen.  Regions  rich  in  sebaceous  and  hair  follicles  are,  as  a  rule, 
less  frequently  invaded  by  simple  than  by  specific  eruptions.  The 
annular  forms  of  simple  erythema  may  occur  on  any  part  of  the  body, 
while  these  forms  of  the  erythematous  and  the  papular  syphilides  are 
more  likely  to  be  limited  to  the  neighborhood  of  joints,  the  anterior 
and  inner  surfaces  of  the  extremities,  and  the  gluteal  regions. 

The  papular  syphilides  are  prone  to  be  developed  on  the  palms  and 
soles. 

Later  eruptions  are  generally  seated  upon  the  nose,  the  lips,  and  the 
scalp ;  they  are  found  upon  the  scapular,  sternal,  and  gluteal  regions, 
and  more  often  on  the  legs,  near  the  joints,  than  on  the  thighs. 


THE  ERYTHEMATOUS  SYPHILIDE.  539 

The  early  eruptions,  especially  the  papular  syphilides,  are  very  likely 
to  form  a  segment  of  a  circle  at  the  border  of  the  scalp,  which  has  been 
called  the  "  corona  veneris."  It  is  a  mistake  to  suppose  that  the  papu- 
lar eruption  is  the  only  one  which  may  be  developed  in  this  way,  since 
most  secondary,  and  even  tertiary,  syphilides  seem  prone  to  thus  develop. 

Peculiarities  of  Ulcers  and  Cicatrices. — Syphilitic  ulcers  may  be 
round,  oval,  kidney-shaped,  or  of  the  form  of  a  horseshoe.  The  ulcers 
of  lupus  frequently  assume  similar  forms,  but  the  lesions  of  syphilis 
are  generally  more  numerous,  more  extensively  distributed,  and  more 
polymorphous  than  those  of  lupus.  The  character  of  the  crusts,  the 
rapid  progress  and  regular  margins  of  the  ulcer,  and  its  proximity  to  a 
joint,  the  general  history  of  the  case,  and  its  amenability  to  treatment, 
distinguish  a  syphilitic  lesion.  The  cicatrices  of  syphilitic  ulcers,  espe- 
cially where  they  have  been  numerous,  are  often  diagnostic.  They  are 
distinctly  rounded  or  oval,  smooth,  and  seldom  traversed  by  fibrous 
bands  except  at  the  joints  ;  they  are  frequently  perforated  with  minute 
holes,  the  sites  of  former  follicles,  wThen  they  are  more  or  less  depressed, 
and  when  mature  are  somewhat  pliable.  Their  brownish-red  color 
slowly  fades  from  the  centre  to  the  periphery,  until  there  remains  a 
white  shining  surface  surrounded  by  a  narrow  areola  of  brown  pigment. 

The  exact  relation  of  herpes  zoster  to  syphilitic  infection  is  a  ques- 
tion yet  to  be  settled,  though  several  authors  entertain  the  opinion  that 
the  dermal  nervous  disturbance  may  in  some  cases  be  etiologically  asso- 
ciated with  the  general  infectious  process.  This  subject  is  worthy  of 
careful  study,  and  until  more  light  has  been  thrown  upon  it  it  is 
not  well  indiscriminately  to  pronounce  all  cases  of  zona  occurring  in 
syphilitics  to  be  due  to  specific  infection. 

THE  ERYTHEMATOUS  SYPHILIDE. 

Syn. — Syphilitic  roseola,  Macular  syphilide,  Exanthematous  syph- 
ilide,  Syphilis  cutanea  maculosa. 

The  erythematous  syphilide  is  usually  the  earliest  syphilitic  erup- 
tion. It  is  probably  present  in  all  cases  of  syphilis,  but  may  escape 
observation  on  account  of  the  extreme  faintness  and  delicacy  of  its  pink 
spots,  or  its  scantiness,  or  by  reason  of  its  forming  only  a  part  of  an 
eruption  which  is  chiefly  papular  or  pustular. 

The  lesion  consists  of  round  or  oval  spots,  with  distinct  or  irregular 
outlines  of  an  average  diameter  of  about  one-half  of  an  inch.  Their 
color  varies  from  a  delicate  rosy  pink  to  a  decided  red  or  even  a  purple 
hue.  In  some  cases  there  may  be  only  a  mottling  of  the  skin,  or  the 
eruption  may  be  so  faint  as  to  be  invisible  except  on  careful  inspection 
or  in   an  oblique  light.     Exposure  to  cold  brings  the  spots  into  promi- 


540  SECONDARY  ERUPTIONS,    OR  SYPHILIDES. 

nence,  while  they  disappear  in  the  general  hyperemia  of  the  surface 
from  increase  of  temperature,  and  show  themselves  more  clearly  in  the 
reaction  which  follows.  At  first  the  spots  may  be  effaced  by  pressure, 
but  about  the  end  of  the  first  month  they  may  assume  a  grayish-brown 
or  coppery  tint  which  is  permanent.  This  tint  appears  earlier  in  exposed 
regions  and  on  the  legs,  perhaps  owing  to  peculiar  conditions  of  the  cir- 
culation. Sometimes  the  eruption  disappears  without  this  change  of 
color.     There  is  seldom  elevation  or  scaling  of  the  surfaces  of  the  spots. 

The  erythematous  syphilide  requires  a  week  or  ten  days  for  its  com- 
plete development,  but  individual  patches  reach  their  full  size  in  a  day 
or  two,  and  show  no  tendency  to  coalesce  or  to  form  circles.  In  cases 
of  great  intensity,  or  in  those  in  which  the  capillary  circulation  is  for 
any  reason  stimulated,  the  whole  body  may  be  covered  by  the  eruption 
in  a  single  day. 

The  spots  may  be  first  seen  in  the  vicinity  of  the  umbilicus,  soon 
extending  to  the  thorax,  sometimes  following  the  line  of  the  ribs,  and 
finally,  in  severe  cases,  being  closely  crowded  over  a  large  portion 
of  the  surface.  In  exceptional  cases  they  appear  first  on  the  face. 
In  mild  eruptions  the  spots  are  most  numerous  on  the  sides  of  the 
trunk  and  on  the  inner  surfaces  of  the  extremities.  On  the  genitals 
of  either  sex  the  macules  are  prone  to  hypertrophy,  and  hence  we  fre- 
quently see  condylomata  lata  coexisting  with  roseolous  patches  in  these 
regions.  Similar  changes  are  noticed  about  the  anus,  the  umbilicus,  the 
nose,  and  the  mouth,  and  in  the  fold  of  integument  below  the  breasts. 
A  limited  number  of  patches  may  be  found  on  the  palms  and  soles 
which  may  be  diffuse  or  slightly  elevated  and  scaly.  The  dorsal  sur- 
faces of  the  hands  and  feet  are  rarely  invaded.  But  it  is  very  common 
to  see  a  well-marked,  even  intense,  eruption  on  the  palms  of  the  hands 
and  the  soles  of  the  feet.  The  spots  are  of  irregular  roundish  outline 
of  deep-red,  even  purplish,  color,  and  are  also  found  scattered  on  the 
fingers.  In  many  cases  little  masses  of  epithelium,  somewhat  salient 
also,  but  deeply  imbedded  in  the  superficies  of  the  skin,  are  seen  scat- 
tered over  the  palm  and  the  fingers,  particularly  near  the  natural  fur- 
rows. This  condition  is  admirably  shown  in  Fig.  131.  A  common 
region  is  the  lower  two-thirds  of  the  forearms  and  the  wrists.  The 
neck  is  frequently  exempt,  or  an  eruption  on  the  trunk  may  extend  by 
occasional  spots  along  the  back  of  the  neck  to  the  scalp. 

The  pale-rose  or  pinkish  eruption,  which  so  often  escapes  detection, 
is  usually  of  ephemeral  duration.  The  spots  rarely  become  elevated, 
and  more  rarely  the  seat  of  scaling,  and  they  disappear  as  they  appeared, 
suddenly  and  quickly.  It  is  not  uncommon  to  see  this  eruption  in  its 
subdued  form  coexist  with  well-defined  erythematous  spots  on  the  face, 
forehead,  and  the  flexor  surfaces  of  the  arms.     (See  Plate  XXXIII.) 


PLATE  XXXIII. 


ERYTHEMATOUS  SYPHILIDE.      PALE   ROSE   ERUPTION. 


PLATE  XXXIV. 


ERYTHEMATOUS  SYPHILIDS.     DEEP  RED  OR   PURPLISH    ERUPTION. 


THE  ERYTHEMATOUS  SYPHILIDE. 


541 


The  second  or  more  hyperaemic  form  of  the  erythematous  syphilide 
usually  appears  by  prompt  and  comparatively  rapid  invasion,  and  is 
often  accompanied  by  marked  elevation  of  temperature,  malaise,  rheu- 
matoid pains,  and  neuralgias.  The  eruption  begins  as  pinkish  or  rosy 
spots,  which  rapidly  become  darker  until  a  rather  deep  pinkish  red  is 
observed.  The  irregularly  and  generally  distributed  spots  are  at  first 
grayish-red,  but  soon  assume  a  purplish  tint.  Very  often  with  this 
deepening  of  color  puncta?  of  even  deeper  hue  appear  at  the  orifices  of 
follicles.     (See  Plate  XXX IV.) 

Fig.  131. 


The  erythematous  syphilide  of  the  palm,  with  epithelial  hyperplasise. 

This  form  of  the  erythematous  syphilide  is  peculiar  in  its  chronicity, 
since  the  purplish  spots  remain  unchanged  for  weeks,  and  perhaps  as 
long  as  three  months.  Then  they  gradually  become  grayish  brown,  then 
coppery,  and  finally  a  yellowish  buff,  when  they  disappear,  the  process 
of  involution  sometimes  occupying  several  months.  More  or  less  des- 
quamation is  often  observed  in  this  syphilide  from  its  period  of  develop- 
ment to  its  decline. 

Circinate  eruption. — In  relapses  of  the  erythematous  syphilide  dur- 
ing the  first  year  of  infection  the  eruption  sometimes  appears  in  the 
form  of  perfect  or  broken  rings.  This  annular  or  circinate  eruption  is 
usually  limited  as  to  the  number  of  the  efflorescences,  and  is  generally 
localized  in  certain  regions.  The  rings  may  be  quite  broad  or  very  thin, 
and  they  may  be  merely  erythematous  or  they  may  be  slightly  elevated 
and   moderately  scaly.     Sometimes  several  rings  or  parts  of  rings  are 


542 


SECONDARY  ERUPTIONS,    OR  SYPEILIDES. 


seen  enclosed  within  a  larger  ring.  In  some  cases  this  enclosure  of  rings 
within  rings  is  strikingly  perfect  in  appearance.  The  neck,  the  fore- 
arm, the  shoulders,  and  the  chest,  and  the  thighs  are  the  most  constant 
sites  of  the  annular  roseolous  syphilide.  There  may  be  as  many  as  fifty 
and  as  few  as  three  or  four  rings.  In  some  cases  this  eruption  shows  a 
marked  tendency  to  relapse,  particularly  within  the  first  two  years  follow- 

Fig.  132. 


Circinate  erythematous  syphilide. 

ing  infection.  In  very  exceptional  cases  this  form  of  eruption  appears 
as  late  as  the  third,  fourth,  or  fifth  year  of  syphilis.  In  some  cases  the 
rings  look  like  deep-seated,  very  dull-red  mottlings  of  the  skin,  par- 
ticularly where  it  is  thin  and  fine.  In  many  instances  patients  com- 
plain that  they  have  these  so-called  ringworms  for  months  and  years. 
These  ringed  eruptions,  as  a  rule,  show  no  tendency  to  peripheral 
increase.     (See  Fig.  132.) 


THE  ERYTHEMATOUS  SYPHILIDE.  543 

Seborrhea  and  Syphilis. — In  some  cases  of  erythematous  syphilide 
of  the  face,  neck,  and  upper  part  of  the  trunk  there  seems  to  be 
an  interlocking  or  symbiosis  of  this  specific  process  with  the  seborrheic 
process,  which  is  caused  by  some  micro-organism.  The  syphilitic  erup- 
tion seems  to  follow  the  evolution  and  development  of  the  seborrhceic 
process.  The  erythematous  spots  become  slightly  elevated  and  decidedly 
scaly,  the  scales  having  the  dirty  and  greasy  appearance  of  those  of  the 
simpler  process.     The  redness  is  dull  and  of  the  salmon  tint. 

The  course  of  the  erythematous  syphilide  is  slow,  and  except  in 
cases  of  active  invasion  it  is  not  attended  by  special  irritation  or  heat 
of  the  skin. 

Its  duration  depends  on  the  degree  of  the  hyperemia  and  on  treat- 
ment. A  faint  rash  often  disappears  spontaneously  within  a  short  time 
under  the  influence  of  mercury.  After  pigmentation  has  taken  place 
internal  treatment  needs  to  be  supplemented  by  the  external  use  of 
mercury  in  ointment,  lotion,  or,  still  better,  the  vapor  bath. 

Diagnosis. — The  diagnosis  of  the  erythematous  syphilide  is  to  be 
made  when  in  its  form  of  hypersemic  patches,  its  pigmented  condition, 
and  its  ringed  form. 

In  its  hypersemic  stage  it  may  be  mistaken  for  rubeola,  scarlatina,  or 
the  erythema  following  the  ingestion  of  balsams  or  the  use  of  mercury. 

The  mode  of  invasion,  the  absence  of  severe  general  symptoms,  and 
the  circumscribed  and  indolent  character  of  the  rash  wTill  usually  enable 
one  to  distinguish  it  from  rubeola  and  scarlatina;  moreover,  the  presence 
of  catarrhal  and  conjunctival  symptoms  in  the  former,  and  of  gastric 
and  throat  symptoms  in  the  latter,  will  be  of  assistance. 

The  rash  caused  by  cubebs,  copaiba,  tar,  etc.,  is  always  attended  by 
high  fever  and  serious  gastric  disturbance,  and  many  of  the  patches  are 
very  large  and  cedematous  or  like  the  wheals  of  urticaria.  The  erup- 
tion soon  fades  on  cessation  of  the  exciting  cause. 

One  of  the  most  frequent  errors  in  the  diagnosis  of  syphilitic  erup- 
tions is  that  of  confounding  the  pigmentary  stains  of  the  erythematous 
syphilide  with  tinea  versicolor.  They  somewhat  resemble  each  other 
in  color,  but  that  of  tinea  is  more  yellow,  and  many  of  its  patches  are 
very  large,  and  they  are  always  accompanied  by  some  extremely  small 
ones.  Tinea  is,  moreover,  slightly  pruritic,  and  its  scales  contain  the 
microsporon  fur/or.  The  patches  of  tinea  are  always  found  over  the 
sternum,  where  syphilitic  eruptions  are  rare,  and  they  are  much  less 
scattered  than  those  of  the  syphilide. 

In  rare  instances  of  slight  elevation  and  scaliness  the  rings  of  the 
erythematous  syphilide  may  be  mistaken  for  tinea  circinata,  particularly 
when  this  eruption  is  of  a  pink  or  red  color.  The  scales  of  tinea  cir- 
cinata always  contain  the  parasite  iricophyton  tonsurans. 


544  SECONDARY  ERUPTIONS,    OR  SYPHILIDES. 

Pityriasis  raaculata  and  circinata  are  sometimes  mistaken  for  the 
erythematous  syphilide.  In  the  simple  eruption  the  patches  are  of  a 
decidedly  more  inflammatory  nature.  There  is  no  history  of  syphilis; 
the  ganglia  are  unaffected,  and  there  are  not  present  on  the  skin,  mucous 
membranes,  or  scalp,  as  there  commonly  is  with  the  erythematous  syph- 
ilide, concomitant  lesions  whose  nature  is  readily  perceptible. 

Treatment. — As  a  rule,  internal  medication  causes  this  syphilide  to 
disappear  promptly,  but  it  is  always  well  to  hasten  its  involution  by 
sublimate  baths,  mercurial  vapor  baths,  or  by  inunction.  Upon  the 
face,  neck,  hands,  and  wrists  this  syphilide  may  be  persistent,  and  its 
disappearance  may  be  hastened  by  using  a  4  per  cent,  white  precipitate 
ointment. 

When  seborrhoea  complicates  the  erythematous  syphilide  it  is  well 
to  rub  the  parts  several  times  a  day  with  resorcin  ointment  (5  to  10  per 
cent). 

THE  PAPULAR  SYPHILIDES. 

These  most  important  dermal  lesions  of  syphilis  are  made  up  of  cir- 
cumscribed infiltrations  into  the  superficial  layers  of  the  skin,  and  pre- 
sent two  varieties — the  conical  or  miliary  and  the  lenticular  or  flat. 

They  may  constitute  the  first  symptom  of  the  secondary  stage,  or  they 
may  be  combined  with  the  erythematous  syphilide.  In  relapses  they  fre- 
quently occur  alone,  or  constitute  by  far  the  larger  proportion  of  a  re- 
curring eruption.  They  may  be  seen  even  in  the  tertiary  stage,  and  they 
merge  into  the  tubercular  syphilide  by  intermediate  grades  of  papulo- 
tubercles.  Some  of  these  intermediary  papules  are  attended  by  an 
epidermal  proliferation,  and  have  therefore  sometimes  been  erroneously 
called  "  squamous  syphilides."  The  various  changes  of  form  and  dis- 
tribution which  the  papules  undergo  sometimes  give  them  a  strong  re- 
semblance to  simple  skin  lesions. 

The  Miliary  Papular  Syphilide. 

The  miliary  papular  syphilide  exists  in  two  distinct  varieties,  one  com- 
posed of  large  and  the  other  of  small  papules. 

Some  of  the  small  papules  are  about  the  size  of  a  pin's  head,  while 
others  are  two  or  three  times  as  large.  They  consist  of  distinctly  limited, 
conical  or  rounded  elevations  of  the  skin,  sometimes  umbilicated,  and  in 
their  early  stages  they  have  a  deep  pinkish-red  color.  When  constituting 
the  first  eruption  of  the  secondary  period  or  an  early  relapse  they  are 
distributed  over  the  whole  body,  sometimes  closely  packed  together,  and 
particularly  copious  on  the  forehead,  about  th$  nose  and  chin,  on  the 
back  of  the  neck,  on  the  outer  surfaces  of  the  extremities,  and  upon  the 
scapular  and  gluteal  regions.     The  papules  may  be  arranged  in  groups 


THE  MILIARY  PAPULAR  SYPHILIDE.  545 

in  the  form  of  circles  or  segments  of  circles,  or  like  the  letter  S  or  the 
figure  8.  Sometimes  the  papules,  composing  rings  which  may  have  a 
diameter  of  half  an  inch  or  two  inches,  fuse  and  lose  their  individual 
shape.  The  circular  form  is  assumed  only  in  the  regions  referred  to, 
while  elsewhere  papules  may  be  seated  without  definite  order. 

In  a  generalized  eruption  papules  may  be  seen  on  the  backs  of  the 
hands  and  upon  the  scrotum  and  penis,  where  they  usually  become  ex- 
coriated and  are  transformed  into  condylomata.  Unlike  the  flat  pupules, 
these  are  rarely  accompanied  by  condylomata  about  the  anus  in  the  male 
and  the  vulva  in  the  female.  After  frequent  relapses  the  papules  are 
generally  less  numerous  and  less  confined  to  particular  regions,  while  the 
ring-form  becomes  a  more  prominent  feature.  When  the  eruption  occurs 
late  in  the  secondary  period  it  may  be  seen  in  but  one  region,  and  may 
even  be  unsymmetrical. 

This  eruption  usually  begins  about  the  face  and  neck,  and  is  fully 
developed  at  the  end  of  two  weeks.  In  some  instances  its  evolution  is 
so  rapid  that  it  has  been  called  the  "  acute  papular  syphilide."  In  late 
relapses  the  papules  appear  as  slowly  as  any  other  syphilitic  eruption. 
Many  of  the  papules  are  seen  at  the  openings  of  follicles — a  feature 
which  is  more  noticeable  in  this  than  in  any  other  form  of  syphilitic 
papule. 

After  their  complete  development  the  papules  remain  unchanged  for 
a  time.  In  some  cases  new  papules,  and  exceptionally  pustules,  appear 
among  the  old  ones.  Soon  their  color  changes  to  a  sombre  brown,  and 
finally  to  a  coppery  hue.  Small  scales  of  epidermis,  frequently  in  the 
form  of  rings,  which  correspond  to  the  margins  of  papules,  are  detached 
by  the  infiltrative  process  beneath. 

Frequently  a  few  of  the  papules  are  converted  into  vesicles  or  pustules 
by  the  accumulation  at  their  apices  of  a  minute  quantity  of  serum  or 
pus.  They  may  remain  in  this  condition  for  a  long  time.  Generally  the 
fluid  dries  and  forms  a  minute  crust  which  may  fall  off  spontaneously, 
leaving  the  papules  apparently  in  their  elementary  state.  In  some  cases 
pustules  form,  which  may  dry  or  become  ulcers. 

When  uninfluenced  by  treatment  the  course  of  the  eruption  is  chronic. 
In  its  early  stage  it  yields  slowly  to  treatment,  but  after  long  duration 
it  becomes  very  chronic,  and  requires  local  as  well  as  general  treat- 
ment. Its  rapid  and  early  disappearance  is  desirable,  since  permanent 
atrophic  spots  like  those  of  variola  remain  after  a  lesion  which  has  had 
a  long  existence.  These  spots  are  pigmented,  and  they  become  white 
only  after  several  months. 

The  diagnosis  is  generally  easy,  at  least  in   the  early  stage.     The 
eruption  may  be  mistaken  for  the  punctate  form  of  psoriasis  or  for  cer- 
tain forms  of  lichen  pilaris  and  lichen  planus. 
35 


546  SECONDARY  ERUPTIONS,    OR  SYPHILIDES. 

In  psoriasis  the  papules  tend  to  form  patches  an  inch  or  more  in 
diameter,  and  the  scales  are  copious,  silvery,  and  imbricated. 

Lichen  pilaris  is  an  inflammatory  affection,  chiefly  of  hairy  regions, 
and  is  accompanied  by  intense  pruritus,  and  the  papules  often  form 
patches  of  thickened  skin. 

In  lichen  planus  the  papules  are  flatter,  less  uniform,  more  commonly 
umbilicated,  are  always  pruritic,  and  are  more  likely  to  lose  their  original 
character  by  confluence. 

Moreover,  with  the  syphilide  we  have  the  specific  history  and  possibly 
the  coexistence  of  other  and  distinctive  lesions. 

This  form  of  papular  syphilide  may  be  mistaken  for  acne,  especially 
on  account  of  its  appearance  on  the  back.  In  acne  the  lesions  are  most 
abundant  about  the  face  and  shoulders ;  they  vary  greatly  in  size,  and 
are  accompanied  by  more  hypersemia.  Acne  usually  begins  about  pu- 
berty and  has  a  history  of  many  recurrences. 

The  Lenticular  Papular  Syphilide. 

There  are  two  varieties  of  flat  papules  caused  by  syphilis — the  small 
and  the  large.  The  small  papules  frequently  occur  in  the  form  of  a 
general  eruption ;  this  is  rarely  true  of  the  large  papules,  which  are 
usually  seen  concurrently  with  a  small  papular  eruption,  an  erythematous 
or  perhaps  a  pustular  syphilide.  These  two  forms  of  papules  present 
striking  differences. 

The  Small  Flat  Papular  Syphilide. 

The  small  papules  begin  as  minute  red  spots,  which  rapidly  increase 
until  they  reach  a  diameter  of  one-eighth  to  one-fourth  of  an  inch  and 
an  elevation  of  one-third  to  one-half  a  line.  They  are  either  round  or 
oval,  have  flat  surfaces,  and  rounded  and  distinctly  limited  margins.  A 
few  papules  may  be  slightly  depressed  at  the  centre,  but  we  do  not  find 
them  surrounding  follicular  openings  or  pierced  with  hairs.  In  the  early 
and  general  eruptions  the  papules  are  scattered  and  show  no  tendency  to 
fuse.  In  relapses  they  are  less  numerous,  and  are  more  likely  to  be 
grouped  and  arranged  in  a  circular  form. 

Mode  of  Distribution. — The  papules  are  first  seen  about  the  shoulders, 
or  at  the  back  of  the  neck,  or  on  the  sides  of  the  thorax,  and  are  soon 
followed  by  others  on  the  forehead  at  the  margin  of  the  hairy  scalp,  with 
perhaps  a  few  on  the  face,  chiefly  about  the  nose,  mouth,  and  chin,  and 
on  the  anterior  surface  of  the  neck,  rarely  on  the  ears.  At  the  same 
time  or  soon  after  the  trunk  is  invaded,  particularly  the  back,  and 
the  papules  may  follow  the  line  of  the  ribs.  As  a  rule,  the  supra- 
and  infraclavicular  regions  are  spared.  The  papules  are  abundant  in 
the  hypogastric  region  ;  but  few  are  seen  over  the  sternum ;  they    are 


THE  SMALL   FLAT  PAPULAR  SY PHIL  IDE. 


547 


numerous  over  the  anterior  surface  of  the  shoulders,  but  comparatively 
sparse  on  the  outer  surface  of  the  arms,  while  they  are  more  numerous 
on  the  inner  or  flexor  surfaces,  especially  near  the  joints.  Few  are  seen 
on  the  dorsum  of  the  hands,  while  the  palms  are  more  freely  supplied. 
They  are  exceptionally  numerous  on  the  gluteal  regions,  and  are  not 
infrequently  found  upon  the  penis,  the  mons  Veneris,  and  in  the  inguinal 

Fig.  133. 


Small  flat  papular  syphilide  of  the  face. 

regions.  They  are  more  plentiful  on  the  inner  than  the  outer  aspects  of 
the  thighs,  and  they  either  do  not  extend  below  the  knees  or  are  sparsely 
distributed  upon  the  inner  surfaces  of  the  legs  and  sometimes  upon  the 
soles.  The  face  is  spared  by  this  syphilide  more  frequently  than  by  the 
small  miliary  variety.  It  sometimes  assumes  the  form  of  the  so-called 
"  corona  Veneris,"  and  occupies  the  forehead  where  the  hat  presses  ;  it  is 
seen  upon  the  alae  nasi  and  about  the  mouth,  and  shows  a  marked  ten- 


548 


SECONDARY  ERUPTIONS,    OR  SYPHILIDES. 


dency  to  development  near  the  junction  of  the  skin  with  mucous  mem- 
branes. In  rare  cases  the  papules  are  very  copious  and  hypertrophic, 
and  really  constitute  papulotubercles  upon  the  face,  where  they  cause  a 
peculiar  expression,  similar  to  that  sometimes  seen  in  true  leprosy,  which 


Fig.  134. 


Papulotubercular  syphilide. 

is  called  by  some  authors  "  syphilitic  leontiasis."     (See  Figs.  133  and 
134.) 

The  color  of  the  small  flat  papules  varies  in  different  regions  of  the 
body  and  in  different  persons.  In  its  early  stage  it  is  a  pinkish-red, 
which  soon  becomes  brownish  or  coppery  ;  this  change  occurs  first  on 
the  face,  especially  the  forehead,  then  on  the  legs.     In  persons  with 


THE  LARGE  FLAT  PAPULAR  SYPHILIDS.  549 

delicate  skin  or  feeble  circulation   the  color  is  at  first  very  light  red, 
which  changes  to  a  light  yellow  tinged  with   brown. 

In  exceptional  cases  a  peculiar  necrotic  change  takes  place  upon  the 
surface  of  many  of  the  papules.  Their  epidermis  is  thrown  off  either 
by  scaling  or  by  molecular  decay,  and  is  replaced  by  a  dirty-brownish 
membrane  of  a  fibrous  nature,  which  is  removed  in  fragments  or  in 
mass  and  exposes  a  granular  ulcerated  surface.  This  seems  to  be  a 
diphtheritic  deposit. 

The  Large  Flat  Papular  Syphilide. 

The  large  flat  syphilitic  papules  are  either  round  or  oval,  and  have  a 
diameter  of  three-eighths  to  one-half  of  an  inch,  and  exceptionally  of 
fully  one  inch.  They  begin  as  minute  spots,  which,  as  a  rule,  rapidly 
increase  in  area.  Their  surface  is  flat,  but  occasionally  there  is  a  well- 
marked  sloping  depression  at  the  centre.  They  are  distinctly  elevated, 
with  rounded,  sharply  defined  edges.  A  few  small  adherent  scales  lie 
upon  the  surface,  and  at  the  margins  of  the  papules  an  epidermal  fringe 
or  rim  may  be  seen.  They  generally  have  a  decidedly  red  color,  which 
soon  becomes  coppery.  In  rare  cases  they  are  bright  crimson-red,  and 
exceptionally  they  have  a  deep  purplish-red  tint.  They  run  a  chronic 
course,  and  cause  neither  pain  nor  itching.  The  surfaces  of  the  papules 
in  rare  instances  undergo  superficial  necrosis  and  become  covered  with 
a  thin,  dirty-looking  diphtheroid  membrane.  Such  an  occurrence  is 
always  indicative  of  a  depressed  condition  of  the  system  and  of  a  severe 
form  of  the  disease. 

This  eruption  occurs  under  a  variety  of  circumstances.  In  some 
instances  a  few  papules  may  be  found  with  an  erythematous  syphilide 
or  an  eruption  of  small  flat  papules  on  the  forehead,  the  neck,  and 
about  the  genitals.  In  rare  cases  this  syphilide  is  the  first  eruption, 
and  it  then  resembles  the  small  flat  variety  in  its  mode  of  appearance 
and  its  course.  It  occurs  upon  the  palms  and  soles  with  about  the 
same  frequency  as  the  latter,  and  in  these  regions  it  may  develop  the 
so-called  palmar  and  plantar  psoriasis.  When  occurring  as  a  first  gen- 
eralized rash  this  syphilide  shows  no  tendency  to  a  circular  arrangement, 
and,  although  the  papules  may  be  more  closely  aggregated  on  such 
parts  as  the  face,  neck,  shoulders,  inguinal  and  gluteal  regions,  and  near 
joints,  they  do  not  coalesce  except  in  parts  continuously  irritated. 
Owing  to  irritation  their  area  sometimes  becomes  greatly  increased. 

This  syphilide  may  also  become  complicated  with  seborrhcea. 

Prognosis. — The  early  appearance  of  this  syphilide  indicates  an 
active  form  of  syphilis,  and  calls  for  prompt  and  careful  treatment.  A 
relapse  of  the  eruption  indicates  continued  activity  of  the  disease.     As 


550  SECONDARY  ERUPTIONS,   OR  SYPHILIDES. 

to  the   eruption  itself,  its  disappearance  is  merely  a  question  of  time 
and  of  treatment. 

Diagnosis. — A  general  eruption  of  this  syphilide  presents  such  dis- 
tinctive features  that  errors  in  diagnosis  are  scarcely  possible.  Where  it 
occurs  in  limited  numbers  and  runs  a  chronic  course,  particularly  when 
there  are  several  eruptions  of  papules  at  short  intervals,  no  other  lesions 
being  visible,  it  may  be  mistaken  for  psoriasis.  The  question  may  be 
still  further  complicated  by  the  appearance  of  papules  upon  the  elbows 
and  knees.  A  distinction  can,  however,  generally  be  made  by  attention 
to  certain  points.  In  syphilis  the  papules  have  a  uniform  size  not  seen 
in  psoriasis  ;  in  psoriasis  the  spots  are  likely  to  blend  and  form  gyrate 
patches  ;  while  in  syphilis  they  gradually  pass  away  after  reaching  ma- 
turity. The  color  of  the  psoriatic  patches  is  pinkish  or  deep  crimson; 
that  of  the  syphilitic  papules  is  deep  brown  or  dull  crimson.  It  must 
be  confessed,  however,  that  a  diagnosis  must,  in  some  cases,  be  estab- 
lished by  other  features.  The  scales  of  the  syphilitic  papules  are  not 
as  copious  and  usually  not  as  silvery  as  those  of  psoriasis ;  they  are 
simply  more  or  less  adherent  flakes  of  epidermis.  Moreover,  in  syph- 
ilis there  is  a  history  of  some  other  symptom  or  lesion,  or  there  may 
be  other  specific  lesions  on  the  body  at  the  time.  There  may  also  be 
cachexia  in  syphilis,  while  patients  with  psoriasis  are  generally  remark- 
ably healthy.  The  age  of  the  patient  is  sometimes  a  point  of  impor- 
tance. As  a  rule,  psoriasis  begins  in  early  life  and  only  exceptionally 
after  puberty.  The  syphilide  is  more  common  after  puberty,  on  account 
of  the  more  frequent  occurrence  of  syphilis  after  that  period.  Finally, 
mercurial  treatment  has  no  effect  upon  psoriasis,  while  it  is  especially 
beneficial  in  this  form  of  syphilide. 

Scaling  Papular   Syphilide  of  the  Palms  and  Soles  (Syphilitic 
Psoriasis  of  the  Palms  and  Soles). 

Papular  syphilides  of  the  palms  and  soles  are  often  peculiar  and 
difficult  of  diagnosis.  They  may  occur  at  any  time  in  the  secondary 
period  or  may  coexist  with  tertiary  lesions  ;  they  run  a  chronic  course, 
unaccompanied  by  pain  and  itching,  and  are  generally  rebellious  to 
internal  treatment. 

The  erythematous  syphilide  is  often  developed  on  the  palms  in  scat- 
tered spots  which  have  a  deep-red  color,  are  slightly  elevated,  and  covered 
by  a  layer  of  epidermis.  In  favorable  cases,  subjected  to  treatment, 
scaling  soon  occurs,  leaving  a  smooth,  rosy,  slightly  depressed  surface, 
surrounded  by  an  undermined  rim  of  epidermis.  The  mode  of  develop- 
ment of  these  spots,  when  not  treated,  will  be  described  later. 

In  a  general  eruption  of  flat  papules  a  few  sometimes  occur  in  the 
hollow  of  the  palms  and  soles.     They  are  small,  decidedly  elevated,  and 


SCALING  PAPULAR  SYPHILIDE  OF  THE  PALMS  AND  SOLES.   551 

have  a  deep-red  or  purple  color,  which  soon  becomes  obscured  by  the 
great  increase  of  epithelial  scales.  This  is  well  shown  in  Fig.  135. 
Exceptionally  they  are  very  numerous  in  the  above  regions.  They  dis- 
appear under  treatment,  but  if  left  to  themselves  they  become  chronic. 

Fig.  135. 


Circumscribed  scaling  papular  syphilide  of  the  palm. 

In  some  cases,  usually  early  in  the  secondary  period  and  coexisting 
with  dermal  or  other  manifestations,  or  perhaps  being  the  only  evidence 
of  syphilis,  a  varying  number  of  small,  firm,  hard,  colorless  elevations 
or  miniature  corns  appear  on  the  palms.  Usually  there  are  about  a 
dozen  on  each  hand ;  there  may  be  only  two  or  three  or  they  may  be 
much  more  plentiful.  They  cause  neither  itching  nor  pain,  but  are 
in  some  instances  tender  under  pressure.  They  run  an  indolent  course 
and  disappear  chiefly  by  scaling.  They  are  composed  of  dense  masses 
of  epidermal  scales  which  can  be  dug  out  with  a  knife. 

The  well-marked  scaling  syphilides  of  these  parts  may  appear  as  early 
as  the  third  month  of  syphilis,  at  the  time  of  a  relapsing  eruption,  or 
even  at  a  much  later  period. 

These  patches  constitute  the  true  scaling  syphilide  of  these  parts,  and 
are  called  by  most  authors  "syphilitic  psoriasis  of  the  palms  and  soles" 
(Fig.  136). 

The  diagnosis  of  the  early  papular  syphilides  of  the  palms  and  soles 
is  generally  easy,  since  neither  eczema  nor  psoriasis  produces  similar 


552  SECONDARY  ERUPTIONS,    OR  SYPHILIDES. 

appearances.  In  their  early  stage  the  color  and  situation  of  the  patches 
indicate  their  nature,  while  the  history  of  the  case  and  the  coexistence 
of  other  syphilitic  lesions  furnish  additional  evidence.  When  the 
patches  are  diffuse  their  resemblance  to  psoriasis  is  almost  perfect.     The 

Fig.  136. 


The  diffuse  scaling  syphilide  of  the  palm. 

latter,  however,  is  often  more  scaly,  is  usually  more  scattered,  and  is 
scaly  from  the  first,  or  begins  as  rosy-red  patches  and  scaling  spots. 
In  many  cases  of  the  syphilitic  eruption,  particularly  when  it  is  quite 
chronic,  only  one  hand  will  be  found  to  be  attacked,  and  that  one  will 
be  that  most  commonly  used  and  subjected  to  friction.  When  this 
eruption  is  developed  rather  late  in  the  course  of  syphilis  it  may 
attack  only  one  hand.  This  unilaterality  of  the  lesion  is  strongly  sug- 
gestive of  syphilis. 

Treatment. — These  eruptions  are  usually  amenable  to  internal 
medication  if  they  are  attacked  early.  But  even  if  internal  treatment 
is  directed,  one  or  other  of  the  external  methods  should  be  used  occa- 
sionally, in  order  to  expedite  their  involution.  The  small  and  large 
miliary  papular  syphilides  are  the  ones  which  are  most  resistant  to 
general  and  local  remedies.  They,  like  all  stubborn  papular  syphilides, 
should  be  treated  by  hot  baths,  either  alkaline  or  sulphur,  and  by  fric- 
tions of  mercurial  ointment.  Mercurial  ointment  is  to  be  rubbed  into 
the  surfaces  vigorously,  each  seance  occupying  from  twenty  minutes 
to  half  an  hour.  Scaling  eruptions  of  the  palms  and  soles,  the 
sequela?  of  the  erythematous  and  papular  syphilides,  are  peculiarly 
obstinate  and  prone  to  relapse.  They  may  be  benefited  by  local  sub- 
limate baths  taken  once  or  twice  a  dav.     Hot  alkaline  baths  with  the 


THE  ACNEFORM  SYPHILID E.  553 

addition  of  bran  are  also  very  efficient.  After  immersion  of  the  parts 
they  should  be  enveloped  in  a  mild  form  of  mercurial  ointment,  such  as 
equal  parts  of  mercurial  ointment  and  cold  cream  or  of  citrine  oint- 
ment similarly  reduced. 

In  some  cases  of  localized  eruption  a  mild  solution  (from  1  to  4  grains 
to  the  ounce),  of  bichloride  of  mercury  in  flexible  collodion  or  trau- 
maticin  may  prove  very  efficient.  Sometimes,  when  the  tendency  to 
scaling  is  very  persistent,  chrysarobin  may  produce  happy  results. 

THE  PUSTULAR  SYPHILIDES. 

These  syphilides  constitute  an  important  group  of  eruptions,  which, 
though  less  common  than  the  erythematous  and  papular  forms,  may 
appear  at  the  earliest  stage  of  syphilis,  at  any  time  in  its  secondary 
period,  or  even  late  in  its  tertiary  period.  They  vary  in  severity  from 
a  mild  and  ephemeral  eruption  to  one  of  the  gravest  character.  The 
size  of  the  pustules  varies  from  that  of  a  pin's  head  to  that  of  a  ten- 
cent-piece;  they  may  be  acuminate,  globular,  or  flat;  they  are  generally 
round,  but  sometimes  oval;  and  they  are  surrounded  by  a  dull,  cop- 
pery-red areola.  Some  have  a  well-marked  papular  base,  the  pustule 
being  a  minor  part  of  the  lesion;  beneath  all  of  them  there  is  more  or 
less  infiltration.  They  may  begin  as  papules  or  as  distinct  pustules. 
They  vary  greatly  in  number,  sometimes  covering  the  entire  body  or, 
on  the  contrary,  being  limited  to  special  regions.  They  show  a  marked 
tendency  to  appear  on  localities  rich  in  hair-  and  sebaceous  follicles, 
while  some  are  prone  to  be  developed  in  particular  regions.  The  pus- 
tules may  be  either  scattered  or  in  groups,  and  are  almost  always 
symmetrically  placed.  Relapses  of  this  syphilide  are  common;  the 
earlier  the  eruption  the  more  rapid  is  its  invasion  and  the  more  numer- 
ous are  its  lesions,  while  later  eruptions  appear  slowly,  in  limited  num- 
bers, and  with  a  marked  tendency  to  localization. 

The  earlier  eruptions,  being  papulopustular,  usually  cause  no  destruc- 
tion of  the  skin;  while  the  late  ones,  being  extensive,  deep,  and  localized, 
leave  cicatrices,  which  remain  pigmented  for  a  long  time,  but  finally 
become  shining  white. 

The  Acneform  Syphilide. 

This  syphilide  is  thus  called  because,  like  acne  vulgaris,  it  attacks 
the  hair-  and  sebaceous  follicles,  and  because  it  is  a  papulopustular 
lesion.  It  consists  of  conical  or  slightly  rounded  pustules,  varying  in 
diameter  and  elevation  from  one-third  of  a  line  to  a  line.  Sometimes 
the  pustules  are  as  small  as  a  pinhead.  They  may  form  the  whole 
eruption,  or  they  may  be  mingled  with  miliary  papules  or  the  erythema- 
tous syphilide. 


554  SECONDARY  ERUPTIONS,    OR  SYPHILIDES. 

When  appearing  at  the  beginning  of  the  secondary  stage  as  a  general 
eruption  the  pustules  are  usually  accompanied  by  fever,  which  sometimes 
reaches  the  highest  point  observed  in  syphilis,  and  by  other  symptoms 
peculiar  to  that  stage.  The  mode  of  invasion  may  be  rapid  or  subacute. 
In  the  former  case  the  small  red  spots  rapidly  become  papular  and  then 
pustular,  the  lesion  reaching  its  full  development  within  twenty-four  or 
forty-eight  hours. 

This  eruption  generally  begins  about  the  face,  scalp,  back  of  the 
neck,  and  shoulders,  and  may  thence  invade  the  trunk  and  extremities, 
being  more  copious  on  the  scapular,  sternal,  and  gluteal  regions  and  on 
the  outer  aspect  of  the  limbs.  We  in  some  cases  find  syphilitic  papules 
or  erythematous  patches  on  the  inner  surface  of  the  arms  and  legs  and 
on  the  anterior  aspect  of  the  trunk.  When  the  pustules  are  scattered 
over  the  entire  body  they  may  be  closely  crowded  or  separated  by 
marked  intervals.  The  first  eruptions  are  always  more  copious  than 
relapses,  in  which  the  pustules  appear  possibly  grouped  in  patches  or  in 
a  ringed  form  about  the  face,  scalp,  or  shoulders,  usually  having  been 
preceded  by  an  erythematous  or  papular  syphilide. 

The  prognosis  of  this  syphilide  is  not  so  good  as  that  of  other 
earlier  forms.  The  eruption  itself  is  troublesome,  and  the  general 
health  is  more  frequently  impaired  after  this  rash  than  after  others. 

Diagnosis. — The  history  of  the  case,  the  presence  of  other  lesions, 
and  the  appearance  of  a  generally  distributed  pustular  syphilide  pre- 
clude the  possibility  of  mistake.  Acne  vulgaris  resembles  it  in  cer- 
tain particulars.  Acne,  however,  generally  begins  about  puberty,  and 
is  confined  to  the  face  and  back,  and  rarely  attacks  the  hair  of  the  scalp. 
It  is  never  attended  by  systemic  reaction.  Moreover,  it  presents  papules, 
pustules,  and  comedones,  which  have  no  uniformity  of  size ;  some  are, 
indeed,  miniature  furuncles,  and  all  have  at  some  time  a  more  or  less 
hypersemic  areola. 

The  diagnosis  of  this  syphilide  is  generally  easy.  Prodromal  symp- 
toms observed  in  small-pox  and  varicella,  such  as  backache  and  eruptive 
fever,  are  noticeably  absent,  and  there  is  much  less  general  disturbance. 
In  the  acute  eruptions  there  are  great  heat  and  tension  of  the  skin,  and 
at  the  outset  small  shot-like  papules  may  be  felt,  which  rapidly  pustu- 
late. More  or  less  diffuse  patches  of  hyperemia,  accompanied  by  sensa- 
tions of  itching  and  burning  of  the  skin,  are  sometimes  present.  Variola 
progresses  so  rapidly  that  its  nature  is  perfectly  clear  after  the  second 
day.  The  slow  development  of  the  syphilitic  eruption  and  the  absence 
of  subjective  symptoms  are  distinctive  points  in  the  diagnosis. 


THE   VARIOLAFORM  SYPHILIDE.  555 

The  Impetigoform  Syphilide. 

This  syphilide,  like  the  preceding,  is  a  pustulocrustaceous  eruption, 
and  attacks  the  more  superficial  layers  of  the  skin,  differing,  however, 
in  the  fact  that  the  lesions  are  not  so  distinctly  circumscribed,  but  have 
a  tendency  to  involve  a  much  greater  surface  and  often  to  assume  a 
serpiginous  character. 

The  resemblance  of  this  eruption  to  simple  impetigo  is  in  the  group- 
ing of  the  pustules,  in  their  fusion,  and  chiefly  in  the  somewhat  similar 
appearance  of  the  crusts.  The  pustules  of  the  specific  eruption  are 
usually  much  larger  and  flatter  than  those  of  the  simple  form,  and  their 
resemblance  is  hardly  so  close  as  to  warrant  the  term  "  impetigoform " 
applied  to  them.  They  dry  so  quickly  into  crusts  that  the  pustular 
stage  soon  ceases. 

In  some  untreated  and  broken-down  cases  these  pustulocrustaceous 
lesions  take  a  serpiginous  course,  invading  the  superficial  layers  of  the 
derma,  generally  of  the  upper  extremities. 

The  course  of  this  eruption  is  usually  very  chronic.  On  its  invasion 
the  pustules  may  be  very  numerous,  or  a  few  only  may  first  appear  on 
the  head.  Thus  for  long  periods  new  pustules  may  appear  as  old  ones 
fade.  In  other  cases  a  general,  extensive  rash  may  run  its  course  in 
a  comparatively  short  time. 

The  prognosis  must  be  based  upon  the  patient's  general  condition  as 
well  as  upon  the  eruption  itself.  The  presence  of  the  eruption,  how- 
ever slight,  is  an  indication  for  careful  and  continued  treatment  and  for 
attention  to  the  patient's  nutrition  and  hygiene. 

Diagnosis. — This  syphilide  may  be  mistaken  for  impetigo  in  its  dis- 
seminated and  in  its  confluent  form.  The  lesions  of  impetigo  retain 
their  pustular  character  much  longer  than  do  those  of  syphilis.  They 
are  attended  by  heat  and  itching  of  the  skin,  and  have  an  inflammatory 
areola;  they  are  much  more  uniform  in  size  than  are  the  pustules  of 
syphilis,  and  their  crusts  are  of  a  greenish-yellow  color  instead  of  the 
greenish-black  of  syphilis.  The  acuteness  of  invasion  in  the  case  of 
large  patches  of  the  simple  eruption  is  in  striking  contrast  with  the 
slow,  painless,  and  indolent  character  of  the  syphilide.  These  features, 
considered  in  connection  with  the  history  of  the  case,  make  the  diagnosis 
clear. 

The  Variolaform  Syphilide. 

This  eruption  is  much  less  common  than  the  acneform  variety,  and 
is  interesting  chiefly  in  its  resemblance  to  varicella  and  variola.  It  is 
rarely  the  first  eruption  of  syphilis,  but  appears  after  any  of  the  early 
rashes. 

It  consists  of  round  superficial  pustules,  the  epidermis  covering  the 


556  SECONDARY  ERUPTIONS,    OR  SYPHILIDES. 

pus  being  rather  thin.  It  begins  in  the  form  of  red  spots,  which  within 
a  day  or  two  become  pustules  with  a  diameter  and  an  elevation  of  one 
or  two  lines.  These  pustules  are  surrounded  by  a  limited,  deep- 
red  areola,  and  there  is  evidently  not  very  much  thickening  at  their 
bases.  When  fully  developed  they  flatten  slightly  at  the  centre,  some 
presenting  marked  umbilication.     (See  Plate  XXXV.) 

These  pustules  have  no  tendency  to  a  follicular  origin,  but  are  found 
on  parts  where  the  skin  is  soft  and  delicate,  frequently,  like  other  syphi- 
lides,  upon  the  forehead  and  at  the  line  of  junction  of  skin  with  mucous 
membrane.  They  are  generally  sparse  on  the  outer  aspect  of  the  ex- 
tremities, more  numerous  on  the  anterior  of  the  trunk,  and  often  abun- 
dant near  the  genitals  and  in  the  inguinal  region. 

The  mode  of  invasion  of  this  eruption  is  generally  rather  slow,  and 
is  seldom  accompanied  by  pronounced  febrile  movement.  It  begins 
about  the  face,  and  thence  spreads  slowly  over  the  body  in  the 
course  of  one  or  two  weeks.  The  crusts,  which  form  when  the  pustules 
reach  their  height,  fall  off,  leaving  pigmented  spots.  Sometimes  new 
crops  rapidly  succeed  old  ones,  so  that  an  eruption  may  last  several 
months.  The  eruption  is  greatly  influenced  by  treatment ;  although 
its  full  arrest  is  difficult,  future  outbursts  may  be  prevented. 

The  prognosis  is  the  same  as  that  of  other  pustular  eruptions. 

The  Ecthymaform  Syphilide. 

There  are  two  varieties  of  this  syphilide,  superficial  and  deep. 
The  superficial  is  the  earlier  eruption,  appearing  at  any  time  dur- 
ing the  first  year  of  syphilis,  and  is  usually  composed  of  a  greater 
number  of  pustules.  The  latter  resembles  those  of  non-specific 
ecthyma  in  having  a  solid,  elevated .  base  surrounded  by  a  crust, 
and  in  their  tendency  to  ulcerate.  The  deep  form  may  be  an 
intermediary  lesion,  or  even  a  rather  late  one.  The  pustules  of 
the  superficial  form  vary  in  diameter  from  one  to  three  lines. 
They  begin  as  slight  red  elevations  of  the  skin,  which  in  a  day 
or  two  become  small  conical  pustules.  The  pustules  gradually  in- 
crease in  size,  and  crusts  are  formed  by  desiccation  of  the  pus.  The 
crusts  grow  in  proportion  to  the  bases  of  the  pustules,  and  their  yellow 
color  soon  becomes  brown,  which  is  rendered  still  darker  by  particles 
of  dirt  and  sometimes  by  admixture  of  a  little  blood.  When  fully 
formed  their  color  is  yellowish-brown  and  their  shape  round  or  conical. 
As  the  pustules  increase  in  size  the  crusts  become  flattened  and  even 
depressed  at  the  centre.  The  base  is  at  first  of  a  bright-red  color,  which 
soon  becomes  a  dull  reddish-brown,  and  it  is  surrounded  by  an  abruptly 
limited  areola.  Beneath  the  crust,  which  is  seldom  firmly  adherent,  is 
an  ulceration,  involving  the  superficial  layers  of  the  derma,  and  having 


PLATE  XXXV. 


THE    VARIOLAFORM    SYPHILIDE. 


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THE    SUPERFICIAL    ECTHYMA-FORM    SYPHILIDE. 


THE  ECTHYMAFORM  SYPHILIDE. 


557 


a  smooth  floor  covered  by  a  grayish-red  film  of  molecular  detritus 
bathed  in  thick  pus. 

The  superficial  ecthymaform  syphilide  begins  by  the  development  of 
pustules  either  in  a  disseminated  or  an  aggravated  form,  about  the  scalp, 
particularly  at  its  junction  with  the  face  and  neck.  They  may  appear 
gradually  and  without  much  febrile  movement,  or  in  a  manner  quite 
the  reverse.  Soon  after  other  portions  of  the  body,  such  as  the  anterior 
surfaces  of  the  legs  and  forearms,  the  trunk,  particularly  on  the  posterior 
surface,  and  the  inguinal  and  gluteal  regions,  may  be  invaded.  (See 
Plate  XXXYI.) 

The  deep  variety  of  the  ecthymaform  syphilide  is  usually  a  rather  late 
lesion,  but  it  is  sometimes  precocious.  In  the  latter  case  it  may  be  very 
malignant,  and  it  is  then  the  expression  of  profound  syphilitic  cachexia. 
This  syphilide  begins  as  a  papulotubercle.     A  round  or  oval  elevation 

Fig.  137. 


The  deep  ecthymaform  syphilide. 


appears,  upon  which  a  quantity  of  yellow  pus  soon  forms,  and  this 
becomes  thicker  and  dries  into  a  crust  of  a  brownish-black  color,  owing 
to  the  effusion  of  a  little  blood.  When  fully  formed  we  find  an  in- 
crusted  papulotubercle,  with  a  diameter  of  one-quarter  to  one-half  of 
an  inch.  The  firm,  deeply  seated  base  has  a  dark,  coppery-red  color 
and  is  surrounded  by  an  areola  of  a  similar  hue.  The  crust  is  generally 
rounded  or  conical,  but  may  flatten  out  as  it  extends.  (See  Fig.  137.) 
A  deep,  punched-out  ulcer,  with  sharply  cut  edges  and  a  smooth,  gray- 


558  SECONDARY  ERUPTIONS,    OR  SYPEILIDES. 

ish-red  surface,  covered  with  a  foul,  rust-colored  pus,  underlies  the 
crust,  which  can  be  removed  with  little  force. 

This  eruption  is  generally  most  abundant  on  the  antero-exterior  sur- 
faces of  the  legs  ;  often  these  pustules  may  form  on  the  corresponding 
surfaces  of  the  arms  or  about  the  face  and  on  the  lower  portions  of  the 
trunk.  It  is  usually  developed  slowly,  appearing  in  crops  of  from  two 
to  twelve  at  intervals  of  one  or  several  weeks. 

The  prognosis  of  this  syphilide  is  variable.  In  the  superficial  form 
the  eruption  often  gives  much  annoyance,  yet  it  may  disappear  without 
leaving  scars.  The  condition  of  the  system  is  always  below  par,  and 
the  prognosis  should  be  governed  in  great  measure  by  the  degree  of  im- 
provement under  treatment.  In  most  cases  a  favorable  result  may  be 
expected  in  the  course  of  a  few  months,  but  in  rare  cases  prolonged 
cachexia  follows. 

The  prognosis  of  mild  and  limited  cases  of  the  deep  variety  is  usu- 
ally good.  In  more  extensive  and  relapsing  cases  the  outlook  is  less 
favorable ;  the  presence  of  the  eruption  indicates  a  depraved  condition 
of  health,  which  is  greatly  aggravated  by  the  irritation  and  drain  of  the 
deep  ulcerations.  A  few  months  of  proper  treatment  will,  however, 
generally  effect  a  cure. 

The  diagnosis  of  this  syphilide  is  almost  always  easy,  although 
it  may  be  mistaken  for  ecthyma.  The  superficial  form  is  to  be  distin- 
guished from  a  similar  ecthyma  by  the  peculiar  course,  situation,  and 
appearance  of  the  syphilitic  pustules  as  compared  with  the  more  inflam- 
matory, pruritic  pustules  of  ecthyma,  which  are  more  uniform  in  size, 
have  yellowish-brown  crusts,  and  much  less  tendency  to  ulceration. 
Moreover,  ecthyma  usually  occurs  on  the  legs  of  broken-down  subjects, 
and  is  an  eruption  of  papules  and  pustules,  the  latter  forming  only 
superficial  ulcers.  In  some  cases  of  phtheiriasis  in  uncleanly  and  un- 
healthy persons  pustulocrustaceous  ulcers,  somewhat  resembling  those 
of  syphilis,  are  seen,  but  with  care  a  diagnosis  can  always  be  made. 
The  discovery  of  the  Pediculus  vestimentorum,  the  presence  of  minute 
blood-crusts  caused  by  the  bite  of  the  insect,  and  very  often  scratch- 
marks,  and  a  general  papular  and  pruritic  condition  establish  the  diag- 
nosis of  phtheiriasis. 

Treatment. — The  early  and  intermediate  pustular  syphilides  require 
sublimate,  mercurial  vapor,  and  sulphur  and  alkaline  baths.  Then  the 
patient's  body  should  be  rubbed  with  mercurial  ointment  or  a  strong 
white  precipitate  ointment.  About  the  face  it  is  imperative  that  these 
lesions  should  be  efficiently  acted  upon,  in  order  to  cause  their  prompt 
disappearance  and  to  prevent  cicatrices. 

Zinc  ointment  to  which  is  added  white  precipitate  in  the  proportion 
of  5  or  10  per  cent,  is  a  very  useful  preparation.     Resorcin  may  also 


MALIGNANT  PRECOCIOUS  SYPHILIDES.  559 

be  used  in  similar  combination  and  strength.  The  encrusted  syphilides 
require  the  use  of  baths  and  fomentations  for  the  removal  of  crusts, 
and  then  calomel  or  iodoform  may  be  dusted  upon  the  raw  surfaces, 
which  should  be  covered  with  absorbent  gauze.  When  these  surfaces 
are  extensive  iodoform  should  be  used  sparingly,  lest  it  produce  a  toxic 
effect,  or  it  may  be  mixed  with  an  equal  quantity  of  subnitrate  of  bis- 
muth and  then  applied  more  freely.  Similar  combinations  of  aristol 
or  resorcin  may  be  used  with  benefit.  Upon  the  raw  surfaces  left  after 
the  removal  of  crusts  a  solution  of  bichloride  of  mercury  (1  :  2000) 
may  be  used  once  or  twice  a  day.  In  these  cases  mercurial  fumigations 
are  often  wonderfully  curative. 

MALIGNANT  PRECOCIOUS  SYPHILIDES. 

These  syphilides  are  of  a  malignant  and  ulcerative  character,  and  are 
usually  found  in  weakly  and  cachectic  patients.  They  occur  in  three 
quite  distinct  varieties. 

The  first  form  is  a  pustular  rash  attended  with  extensive  ulceration 
and  formation  of  scabs.  It  begins  as  rounded  pustules,  grouped  or 
irregularly  scattered,  which  soon  ulcerate  and  form  flat  or  conical 
greenish-black  crusts  which  may  blend  together.  The  ulcers  are  deep, 
with  sharply  cut,  undermined  edges  and  a  foul  base  secreting  a  fetid 
pus.  Such  an  eruption  appears  first  upon  the  face  or  scalp,  where  the 
lesions  are  often  in  groups ;  then  it  invades  the  arms,  and  may  even 
extend  over  the  entire  body,  successive  crops  of  pustules  being  de- 
veloped in  severe  cases.  There  is  rarely  a  tendency  to  ringed  distribu- 
tion, but  sometimes  one  group  of  pustules  is  increased  by  the  formation 
at  its  periphery  of  new  pustules. 

The  second  form  begins  as  a  red  tubercle  of  the  size  of  a  pea, 
which  is  rapidly  converted  into  an  ulcer  with  a  thick  crust.  The 
subsequent  course  is  similar  to  that  of  the  previous  variety,  except 
that  the  destruction  of  tissue  is  often  much  greater.  This  eruption  is 
prone  to  appear  first  on  the  head  and  upper  extremities.  In  some 
cases  these  regions  only  are  attacked  ;  in  others  the  whole  bodv  is 
invaded.  The  invasion  of  this  eruption,  like  that  of  the  preceding  one, 
may  be  rapid  or  slow.  Its  course  is  chronic,  sometimes  occupying  six 
or  eight  months  or  even  a  year. 

The  third  form  is  one  of  the  most  formidable  manifestations  of 
syphilis,  and  is  happily  rare.  It  is  always  accompanied  by  cachexia, 
and  if  not  fatal  always  leaves  a  condition  of  permanent  ill-health.  It 
begins  as  round  tubercles  of  a  dark-red  color,  slightly  elevated  and 
deeply  seated  in  the  skin,  which  attain  a  diameter  of  an  inch  or  more. 
A  small  blackish  slough  forms  in  the  centre  of  each  tubercle,  and  is 
at  first  firmly  adherent ;  it  extends  rapidly,  and,  soon  becoming  loosened 


560  SECONDARY  ERUPTIONS,    OR  SYPHILIDES. 

by  the  secretions,  is  cast  off  as  a  fetid,  cup-shaped  mass,  looking  some- 
thing like  an  inverted  rupia  crust.  The  ulcer  thus  exposed  is  very 
deep,  has  a  foul,  dark-brown  surface  with  hard,  everted  edges,  and 
secretes  a  fetid  ichor.  To  the  touch  it  gives  the  impression  of  being 
deeply  seated  and  indurated  like  a  typical  initial  lesion  or  chancre. 
Surrounding  each  tubercle  is  a  broad,  deep-red  areola.  Phagedena 
may  occur  and  run  a  course  similar  to  that  of  phagedenic  gummous 
ulcers.  From  time  to  time  brownish-green  crusts  form  and  are  thrown 
off.  In  favorable  cases  the  surface  of  the  ulcer  gradually  assumes  a 
more  healthy  appearance,  the  edges  become  softer,  and  healing  takes 
place. 

The  invasion  of  this  syphilide  is  generally  rapid,  but  its  subsequent 
course  is  slow.  Usually  tubercles  are  developed  in  region  after  region, 
followed  perhaps  by  additional  crops.  They  are  irregularly  scattered, 
with  no  tendency  to  a  ringed  form.  The  face,  the  extremities,  the 
shoulders,  and  buttocks  are  its  favorite  seats. 

The  prognosis  of  these  syphilides  is  always  grave,  since  they  indi- 
cate a  most  intense  and  active  form  of  syphilis.  The  health  of  the 
patient  previous  to  infection,  his  habits,  the  extent  and  character  of  the 
eruption,  and  the  degree  of  cachexia  must  all  be  considered.  The  course 
of  the  lesions  and  the  influence  of  treatment  must  be  watched. 

As  regards  treatment,  every  effort  should  be  made  to  improve 
nutrition.  Much  can  be  done  toward  checking  the  course  of  the 
eruption  by  the  employment  of  local  measures.  Careful  dressing  of  the 
ulcers,  their  thorough  disinfection,  and  the  early  removal  of  secretions 
not  only  add  to  the  comfort  of  the  patient,  but  promote  healing.  The 
local  measures  detailed  for  the  treatment  of  pustular  and  encrusted 
syphilides  may  be  used  for  these  eruptions.  (See  page  558.)  In  spite  of 
every  precaution  indelible  cicatrices  are  generally  left.  Internal  treat- 
ment must  also  be  employed.  The  guarded  use  of  mercury,  preferably 
by  inunction  or  by  hypodermic  injection,  with  iodide  of  potassium, 
sodium,  or  ammonium  internally,  is  indicated.  Opium  is  often  par- 
ticularly useful  in  these  cases  by  calming  the  restlessness  of  the 
patient  and  quieting  the  pain  of  the  ulcers. 

We  may  sometimes  resort  to  mercurial  vapor  baths  with  iodide  of 
potassium  or  sodium,  combined  with  bitter  tonics,  internally,  beginning 
with  ten-  to  fifteen-grain  doses  three  or  four  times  a  day,  and  gradually 
increased  by  two  or  three  grains  daily.  Mercury  given  in  this  way  is 
supposed  to  have  a  beneficial  local  as  well  as  general  effect.  The  con- 
dition of  the  stomach  demands  that  the  most  digestible  and  nutritious 
food  be  taken,  if  possible  in  small  quantity  and  at  frequent  intervals. 
Stimulants,  preferably  port  wine  or  brandy,  must  be  given  regu- 
larly.    Such  treatment  as   the  above    is  suitable  when  the  patient  is 


PRECOCIOUS  QUMMATA.  561 

still  able  to  move  about.  In  a  typhoid  condition  treatment  applicable 
to  the  adynamic  fevers  is  called  for,  together  with  the  careful  use  of  the 
iodides. 

PRECOCIOUS  GUMMATA. 

There  are  three  distinct  varieties  of  early  or  precocious  gummata — a 
generalized,  a  localized,  and  a  neurotic  variety. 

The  generalized  form  appears  as  early  as  the  eighth  week  of  infec- 
tion, and  at  any  time  during  the  first  and  early  parts  of  the  second 
year,  the  rule  being  that  the  earlier  the  date  of  appearance  the  more 
extensive  is  the  eruption  and  the  more  numerous  the  lesions.  It  begins 
in  the  form  of  small  circumscribed  swellings  under  the  skin,  usually 
unattended  with  pain  and  only  perceptible  to  the  touch.  In  a  short 
time  these  become  adherent  to  the  skin,  and  then  they  appear  like 
bright-red  spots,  which  are  frequently  looked  upon  as  blind  boils. 
Thus  early  they  are  found  to  be  round  or  oval  tumors  of  the  size  of  a 
bean  deeply  set  in  the  skin.  They  grow  quite  rapidly,  and  within  ten 
days  may  attain  an  area  of  an  inch  or  inch  and  a  half.  A  slower 
growth  is  also  seen.  As  they  increase  in  size  their  red  color  becomes 
more  sombre,  and  perhaps  coppery.  When  fully  developed  they  pre- 
sent a  quite  firm  structure,  and  may  be  said  to  be  in  the  stage  of 
condensation.  Their  course  is  usually  without  much  variation.  As 
they  grow  older  their  red  color  becomes  more  coppery,  and  they 
gradually  grow  softer  in  structure,  as  if  they  were  permeated  with 
fluid.  This  may  be  called  the  stage  of  softening,  which  varies  in 
degree  in  different  cases.  In  some  tumors  there  is  simply  a  soft,  yield- 
ing condition  of  the  tissues ;  in  others,  what  appears  to  be  true  fluc- 
tuation may  be  felt.  To  the  inexperienced  these  tumors  in  the  latter 
case  may  give  the  impression  of  abscesses  and  suggest  the  use  of  the 
knife,  which,  however,  should  not  be  used,  since  absorption  may  occur 
even  in  this  stage  of  liquefaction  of  the  gummy  infiltration.  Under 
favorable  circumstances  these  lesions  do  not  go  on  to  ulceration,  and 
they  are  then  said  to  belong  to  the  resolutive  variety  of  this  early  form 
of  gummata.  Then  the  tumors  gradually  lose  the  slight  convex  eleva- 
tion which  they  had  attained,  and  slowly  flatten  out,  while  they  gradu- 
ally melt  away  from  their  outer  edge,  their  color  fading  pari  passu 
until  a  pigment-spot  is  left  which  is  most  persistent  upon  the  legs. 
Slight  or  deep  cicatrices  may  also  be  left. 

In  some  cases  the  resolutive  tendency  in  this  eruption  is  not  ob- 
served, but  a  necrobiotic  action  soon  appears.  The  stage  of  condensa- 
tion is  then  quite  short  and  softening  begins  early.  The  centre  of  the 
tumors  assumes  a  dark-red  color  in  one  or  in  several  spots,  and  distinct 
fluctuation  is  soon   made  out.     Then  slight  ulceration  begins,  usually 

36 


562  SECONDARY  ERUPTIONS,    OR  SYPHILIDES. 

in  several  places,  corresponding  to  the  follicular  openings,  and  very 
soon  the  epidermal  roof  of  the  tumor  melts  away,  and  an  unhealthy 
ulcer  with  a  slightly  fungating  greenish-red  floor,  covered  with  a  sanious 
pus  and  surrounded  by  a  thickened,  deep-red,  undermined,  and  more 
or  less  everted  edge,  is  seen.  As  a  rule,  however,  these  precocious 
gummatous  ulcers  are  more  superficial  than  the  tertiary  ones ;  their 
floor  is  less  deep,  their  edges  less  undermined  and  everted,  and  their 
whole  appearance  indicates  that  the  destruction  is  less  extensive. 

The  localized  form  of  early  gummata  appears  somewhat  later  than 
the  preceding  one ;  that  is,  at  about  the  fifth  month  and  within  the  first 
year  of  infection,  and  perhaps  later.  The  difference  between  the  two 
is  mainly  that  of  degree  and  extent  of  development  of  the  lesions. 
Like  the  first  variety,  the  evolution  of  the  tumors  is  aphlegmasic,  but 
a  little  more  indolent  and  insidious ;  in  short,  partaking  to  a  certain 
extent  of  the  characteristics  of  both  the  very  early  secondary  and  ter- 
tiary gummata.  The  tumors  present  the  same  appearance,  except  that 
they  are  large  and  perhaps  not  quite  as  salient  as  those  of  the  first 
variety. 

The  neurotic  form  of  the  early  gummata  has  a  marked  individuality 
of  its  own,  and  presents  points  of  resemblance  to  erythema  nodosum. 
In  the  very  early  months  of  syphilis,  either  in  the  stationary  period  of 
an  early  syphilide  or  at  its  decline,  generally  preceded  or  accompanied 
by  severe  neuralgic  symptoms  involving  the  facial  or  cranial,  intercostal, 
anterior  crural,  or  any  cutaneous  nerve,  by  cephalalgia  continuous  or 
nocturnal,  by  rheumatoid  pains  in  the  muscles  or  joints,  and  by  malaise 
and  debility,  this  eruption  makes  its  appearance  early  and  devel- 
ops quite  rapidly.  In  some  instances  so  acute  is  the  invasion  that 
in  a  week  we  may  find  fully  developed  tumors  an  inch  or  two  long, 
but  in  general  their  evolution  is  less  rapid.  In  addition  to  the 
neuralgic  phenomena,  local  pains  on  the  sites  of  the  lesions  or  on 
the  whole  territory  or  limb  on  which  they  are  developed  are  com- 
plained of.  These  pains  may  be  continuous  or  intermittent,  and  in 
some  instances  are  as  excruciating  as  in  severe  herpes  zoster.  They 
are  described  as  flashing,  burning,  lancinating,  and  are  sometimes  said 
to  resemble  those  of  an  abscess.  In  some  instances  the  patient's  suf- 
ferings are  less  after  the  evolution  of  the  syphilide,  but  in  most  cases 
the  tumors  are  so  painful  that  patients  shrink  in  terror  from  their  pal- 
pation. There  is  also  a  moderate  febrile  movement,  an  evening  tem- 
perature of  100°  or  101°  F.,  and  in  very  severe  cases  as  high  as 
104°  F.  ;  emaciation,  want  of  appetite,  and  concomitant  symptoms. 
The  seats  of  predilection  are  the  forearms  and  legs,  but  the  tumors 
may  appear  on  the  shoulders,  arms,  thighs,  chest,  and  trunk. 

The  eruption  consists  of  two  orders  of  lesions  :  first,  oval  or  round 


THE  PIGMENTARY  SYPH1L1DE.  563 

tumors,  or  irregular  plaques  from  fusion  of  tumors  ;  second,  tumors  or 
nodosities  seated  in  the  subcutaneous  tissues,  at  first  freely  movable 
under  the  skin  and  fascia?,  and  later  on  adherent  by  both  their  upper 
and  lower  surfaces. 

The  cutaneous  tumors  begin  by  infiltration  in  the  deeper  portions  of 
the  skin  and  its  contiguous  connective  tissue.  When  first  seen  they  are 
in  bright-red  and  rather  sharply  circumscribed  spots,  which  soon  form 
round  or  oval  swellings,  slightly  raised  and  convex.  In  some  cases  the 
bright-red  color  rapidly  becomes  darkened  until  a  blackish-red  or  de- 
cidedly ecchymotic  appearance  is  seen,  while  in  others  it  is  of  a  deep 
red  similar  to  that  of  erythema  nodosum.  In  some  cases,  again,  the 
red  centre  pales  and  becomes  the  color  of  white  wax  or  of  a  billiard 
ball,  while  the  deep-red  border  or  areola  remains  in  various  stages  of 
intensity,  consisting  of  a  commingling  or  play  of  colors,  such  as  we  see 
following  a  bruise  or  erythema  nodosum.  In  many  cases  resolution 
takes  place  ;  in  others  the  stage  of  softening  may  end  in  ulceration. 
The  resulting  ulcers  present  all  the  characters  of  the  late  gummata, 
except  that  they  are  rather  more  superficial.  Their  subsequent  course 
is  usually  chronic  and  aphlegmasic. 

The  diagnosis  of  these  lesions  is  usually  very  easy.  The  history 
of  the  case  and  the  subacute  character  of  the  swellings  are  so  distinctly 
different  from  erythema  nodosum  that  a  mistake  can  hardly  occur. 

Treatment. — The  early  or  precocious  gummata  indicate  the  neces- 
sity for  the  use  of  the  mixed  treatment,  or  of  iodide  of  potassium  in 
combination  with  mercury  applied  locally.  Daily  inunctions  should  be 
made,  and  lint  spread  with  mercurial  ointment  should  be  bound  upon 
the  parts.  If  much  pain  is  present,  belladonna  ointment  may  be  mixed 
with  the  mercurial  ointment. 

THE  PIGMENTARY  SYPHILIDE. 

The  pigmentary  syphilide  is  seen  in  three  well-marked  and  quite 
distinct  conditions  : 

1.  In  the  form  of  spots  or  patches  of  various  sizes. 

2.  As  a  diffuse  pigmentation  of  greater  or  less  intensitv,  which  sooner 
or  later  becomes  the  seat  of  leucodermatous  changes  in  the  shape  of 
small  spots  which  gradually  increase  in  size.  This  is  the  retiform  pig- 
mentary syphilide. 

3.  In  an  abnormal  distribution  of  the  pigment  of  the  skin,  in  which, 
owing  to  the  lack  of  or  crowding  out  of  the  pigment  in  places,  they  be- 
come whiter,  while  the  parts  involved  in  the  abnormal  distribution 
become  darker  ;  in  this  May  a  dappled  appearance  is  presented.  In  this 
form  there  is  probably  no  excess  of  pigment  ;  it  is  seeminglv  unequally 
distributed  throughout  the  tissue-expanse.     This  form  has  been  termed 


564  SECONDARY  ERUPTIONS,    OR  SYPHILIDES. 

the  marmoraceous,  from  its  resemblance  to  some  forms  of  marble  in 
which  there  is  an  intimate  interblending  of  light  and  darker  colors. 

All  forms  of  the  pigmentary  syphilide  appear  both  early  and  late  in 
the  secondary  period,  and  they  may  be  the  only  evidence  of  the  diathesis 
or  they  may  coexist  with  other  manifestations.  The  evolution  of  this 
syphilide  may  occur  as  early  as  the  second  or  third  month,  but  it  usually 
appears  about  the  sixth  month  or  toward  the  close  of  the  first  year,  or  it 
may  develop  during  the  second  or  third  year  of  infection.  It  occurs 
most  commonly  in  females,  particularly  blondes,  up  to  the  age  of  thirty 
or  thirty-five  years.     It  is  rarely  found  in  the  male  sex. 

The  parts  of  predilection  of  the  syphilide  are  the  lateral  surfaces  of 
the  neck,  less  frequently  the  face,  and  then  more  commonly  the  forehead. 
It  may  be  seen  on  the  trunk,  arms,  and  legs,  and  may,  very  exception- 
ally, slowly  invade  the  whole  body.  It  is  unattended  by  any  subjective 
symptoms  whatever.  The  pigmentary  syphilide  is  peculiar  in  the  fact 
that  it  is  wholly  uninfluenced  by  internal  treatment,  and  external  appli- 
cations have  little  if  any  effect  upon  it. 

The  pigmentary  syphilide  in  the  form  of  spots  or  patches  consists  of 
round,  oval,  or  irregular  plaques,  which  may  have  sharply  defined  borders 
or  their  margins  may  be  dentated  or  jagged.  Their  color  varies  from  a 
light-brown  cafe-au-lait  to  a  quite  deep-brown  tint.  They  are  unaf- 
fected by  pressure  and  the  condition  of  the  circulation.  In  persons  with 
light  and  delicate  skin  they  may  be  very  faint  in  tint  and  perhaps 
only  perceptible  in  oblique  light. 

In  this  form  of  pigmentary  syphilide  it  is  common  to  see  the  uneven 
distribution  of  the  pigmentation  ;  sometimes  the  color  is  deeper  at  the 
margin.  Commonly  there  is  no  involvement  of  the  intervening  skin, 
though  sometimes  the  hyperchromatous  condition  produces  the  illusion 
that  the  unaffected  skin  is  whiter  than  normal.  These  pigmented  spots 
may  remain  unchanged  and  indolent  for  months,  particularly  in  cold 
weather.     In  the  course  of  time  they  slowly  disappear. 

The  second  form  of  pigmentary  syphilide — the  lace  or  retiform 
variety — is  far  more  common  than  the  other  forms.  Slowly  or  rapidly 
the  sides  of  the  neck  become  discolored  the  tint  being  that  of  cafe-au-lait, 
or  even  of  decided  yellowish-brown.  The  most  common  site  of  this 
eruption  is  on  the  sides  of  the  neck,  and  perhaps  on  the  back  of  the  neck. 
(See  Plate  XXXVII.)  The  patients  usually  say  that  they  noticed  or 
were  told  that  their  necks  were  getting  or  had  got  dirty.  In- 
telligent and  observant  patients  will  very  often  state  that  their 
trouble  began  with  a  browning  of  the  skin,  and  they  will  state  posi- 
tively that  there  was  no  intermingling  of  white  spots.  From  the 
neck  this  eruption  may  extend  extensively  over  the  trunk,  mostly 
anteriorly  or  down    the    arms.       When    the    pigmented    patch    has    in 


PLATE  XXXVII. 


PIGMENTARY  SYPHILIDE    (RETIFORM) 


THE  PIGMENTARY  SYPHILIDE.  565 

volvecl  more  or  less  of  the  sides  of  the  neck,  a  peculiar  change  will  be 
observed  in  it — namely,  the  development  of  whitish  spots  which  maybe 
taken  for  leucoderma.  Scattered  irregularly  over  the  pigmented  surface 
close  observation  will  show  a  few  or  many  minute  white  specks,  which  in 
a  short  time,  particularly  in  hot  weather,  become  large  enough  to  present 
definite  shapes,  which  may  be  round,  oval,  linear,  or  irregular.  These 
white  spots  gradually  grow,  and  in  many  instances  the  neck  is  largely 
covered  with  them  before  the  patient  is  aware  of  any  change  having  taken 
place.  They  then  say  or  are  told  that  their  necks  are  growing  white. 
Toward  the  final  stage  of  the  disease  the  preponderance  of  the  white 
spots  leaves  only  round,  oval,  or  wavy  lines  or  strands  of  brown  pig- 
ment, which  give  the  appearance  of  lace  with  large  meshes,  the  inter- 
stices being  formed  by  the  white  spots,  which  are  round,  oval,  gyrate, 
linear,  or  irregular.  In  this  way  the  skin  in  the  course  of  months,  and 
in  some  cases  of  a  year  or  more,  seemingly  returns  to  its  normal  condition. 

The  third  or  marmoraceous  form  of  pigmentary  syphilide  is  by  far  the 
least  common.  Its  mode  of  invasion  is  slow  and  aphlegmasic,  and  there 
is  little  or  no  hyperpigmentation.  The  natural  color  of  the  skin,  in 
spots  of  irregular  size  and  shape,  becomes  white,  while  the  margins, 
which  are  hazy  and  indefinite,  become  browner  than  normal.  It  seems 
to  be  a  displacement  of  pigment  resembling  strikingly  some  delicate 
varieties  of  marble  in  which  there  are  imperceptibly  blended  shades  of 
white  and  very  light  black.  In  my  experience,  this  form  is  always  seen  on 
the  sides  of  the  neck,  and  it  does  not  show  a  tendency  to  extend.  It  can 
only  be  found  upon  persons  of  delicate  skin,  and  very  often  only  by  close 
observation.     It  slowly  disappears  and  the  skin  is  left  in  its  normal  color. 

Diagnosis. — In  the  stage  of  superpigmentation  the  case  may  be  mis- 
taken for  chloasma  if  the  history  is  not  clearly  brought  out.  When  the 
white  spots  have  become  plainly  visible,  a  diagnosis  of  leucoderma  may 
be  made.  But  usually  the  situation  of  the  eruption,  chiefly  on  the  sides 
of  the  neck,  will  point  to  its  specific  nature.  Then,  again,  in  leucoderma 
the  white  patches  have  a  distinctly  brown  though  narrow  margin,  which 
is  never  seen  in  the  pigmentary  syphilide.  The  diagnosis  of  the  syphilide 
from  tinea  versicolor  is  readily  made.  This  eruption  rarely  exists  on  the 
sides  of  the  neck  alone,  and  if  present  there  is  continuous  with  large 
patches  on  the  trunk.  It  is  usually  darker  in  color,  slightly  elevated, 
and  scaly,  and  may  be  attended  with  mild  pruritus.  If  a  few  scales  are 
removed  and  microscopically  examined,  the  microsporon  furfur  will  be 
readily  seen  among  the  epithelial  cells.  The  pigmentary  syphilide  is  not 
a  scaling  affection,  and  if  scales  arc  scraped  from  the  surface  no  micro- 
organism  will  be  found. 

Treatment  consists  in  daily  frictions  with  mercurial  ointment  or 
douches  with  a  bichloride  solution  (1  :  1000). 


CHAPTER   XXXII. 

SYPHILITIC  AFFECTIONS  OF    THE  VARIOUS  MUCOUS  MEM- 
BRANES. 

ERYTHEMA,  AND  MUCOUS  PATCHES  OF  THE  MOUTH  AND 

TONGUE. 

The  mucous  membranes  continuous  with,  and  rather  remote  from, 
the  mucocutaneous  junctions  are  frequently  affected  in  the  secondary 
stage  by  hypersemic  and  hyperplastic  processes. 

Erythema  of  the  mucous  membranes  is  usually  identical,  in  the  time 
of  its  appearance  and  in  its  general  character,  with  the  same  eruption 
upon  the  skin.  Like  the  latter,  it  ordinarily  appears  six  or  eight  weeks 
after  infection,  and  may  affect  any  of  the  outlets  of  mucous  canals, 
although  it  is  most  frequently  seen  upon  the  fauces,  pituitary  mem- 
brane, and  genital  organs,  and  in  many  instances  doubtless  fails  to 
attract  attention.  It  is  most  frequently  seen  upon  the  fauces  in  persons 
exposed  to  sudden  changes  of  temperature,  in  smokers,  and  in  those 
who  are  subject  to  frequent  attacks  of  catarrh ;  upon  the  vulva  in 
women  who  have  frequent  sexual  intercourse  ;  and  upon  the  glans  penis 
in  men  with  a  long  prepuce.  It  may  be  the  only  general  lesion  present, 
or  more  frequently  it  is  accompanied  by  other  early  manifestations. 

This  eruption  often  disappears  quite  suddenly,  and  is  very  prone  to 
return. 

Erythema  and  Mucous  Patches  of  the  Mouth. 

Erythema  of  the  buccal  cavity  is  usually  confined  to  the  neighbor- 
hood of  the  fauces,  and  in  the  neighborhood  of  the  outlet  of  mucous 
canals,  especially  around  the  genital  organs  and  anus,  upon  the  mucous 
membrane  of  the  mouth,  and  sometimes  upon  other  parts  of  the  body, 
more  particularly  at  the  base  of  the  nails  and  wherever  the  reflection 
of  the  integument  upon  itself  forms  natural  folds  in  the  skin. 

It  may  readily  be  confounded  with  the  effects  of  an  ordinary  cold,  from 
which  it  often  can  be  distinguished  only  by  the  history  of  the  case.  The 
presence  of  narrow,  dusky-red  bands  of  inflammation  along  the  border 
of  the  velum,  ending  abruptly  at  the  base  of  the  uvula,  is  considered 
by  some  observers  to  be  characteristic  of  syphilitic  erythema.  Asso- 
ciated with  this  condition,  as  well  as  with  other  lesions,  there  is  often  a 
general  oedema,  especially  of  the  velum  and  uvula.  The  latter  organ 
may  become  very  much  swollen. 

566 


SUPERFICIAL   AFFECTIONS  OF  THE  TONGUE.  567 

The  most  common  syphilitic  lesions  of  the  mouth  are  mucous  patches. 
They  are  most  frequently  found  upon  the  tonsils,  the  uvula,  the  velum 
palati  and  its  pillars,  the  sides  of  the  tongue,  and  the  mucous  surfaces 
of  the  lips,  especially  the  lower.  At  the  angles  of  the  mouth  they  are 
often  continuous  with  a  pustular  eruption  upon  the  integument.  The 
inner  surface  of  the  cheek  near  the  last  molar  tooth  is  another  favorite 
seat.  The  dorsum  of  the  tongue  and  the  gums  are  less  frequently 
affected.  Their  most  characteristic  feature  is  a  grayish-white  color, 
appearing  as  if  they  had  been  pencilled  over  with  a  crayon  of  nitrate 
of  silver,  which  has  given  them  the  name  of  "  opaline  patches."  They  are 
more  irregular  in  their  outline  than  condylomata,  and,  unlike  the  latter, 
are  not,  as  a  general  rule,  perceptibly  elevated  above  the  surface. 

The  name  "  smokers'  patches "  has  been  given  to  certain  morbid 
areas  most  frequently  seen  on  the  mucous  lining  of  the  cheeks  near  the 
angles  of  the  mouth.  They  occur  most  frequently  in  the  mouths  of 
inveterate  smokers,  and  are  due  to  proliferation  of  the  epithelium, 
which  becomes  opaline,  as  though  the  spots  had  been  touched  with  car- 
bolic acid  or  with  nitrate  of  silver ;  the  patches  are  sometimes  fissured, 
and  may  become  eroded,  although  the  epithelium  is  usually  very  ad- 
herent. They  are  generally  quite  obstinate,  and  persist  long  after  the 
apparent  extinction  of  the  infection. 

Treatment. — Mucous  patches  of  the  mouth,  from  which  infection 
so  often  occurs  to  innocent  persons,  should  be  carefully  and  regularly 
treated.  The  morbid  parts  may  be  touched  with  a  tampon  moistened 
with  a  solution  of  nitrate  of  silver  (30  gr.  to  water  1  ounce),  or  this  may 
be  used  as  a  spray.  The  mouth  should  be  constantly  rinsed  and  the 
throat  gargled  with  strong  solutions  of  borax,  chlorate  of  potassium,  and 
alum.  Particular  attention  should  be  paid  to  the  condition  of  the 
stomach,  and  plain,  nutritious  food  should  be  allowed.  Smoking  is  to 
be  absolutely  interdicted,  and  the  use  of  stimulants  and  irritating  con- 
diments is  to  be  suspended. 

In  some  cases  the  application  of  a  1  or  2  per  cent,  watery  solution  of 
chromic  acid  is  very  efficacious. 

Superficial  Affections  of  the  Tongue. 

Coincidently  with  pharyngeal  erythema  the  mucous  membrane  of 
the  tongue  may  also  become  hyperaeraic.  In  some  cases  the  morbid 
process  extends  over  the  whole  tongue,  while  in  others  it  occurs  in  the 
form  of  round  or  oval  disks  scattered  over  the  dorsum.  From  these 
hyperoemic  patches  the  epithelium  may  be  removed,  and  as  a  result  the 
surface  is  eroded  or  perfectly  smooth,  in  the  form  of  plaques,  of  which 
there  may  be  one  or  several.  This  condition,  somewhat  frequently 
seen  in  syphilis,    is    also  observed    in    the    mouths  of    non-syphilitics, 


568  SYPHILITIC  AFFECTIONS  OF  VARIOUS  MUCOUS  MEMBRANES.  ' 

particularly  in  those  who  suffer  from  gastro-intestinal  troubles.  Ex- 
coriated or  smooth  round  or  oval  patches  of  the  tongue  are  not,  there- 
fore, pathognomonic  of  syphilis. 

Not  uncommonly  we  see  scattered  over  the  tongue  and  at  its  tip 
and  sides  irregular  patches  of  epithelial  hyperplasia  which  have  a 
bright  or  a  dull  pearly-white  surface.  These  lesions,  due  to  circum- 
scribed areas  of  hyperemia,  are  as  small  as  a  pin's  head  and  perhaps 
of  the  extent  of  one  or  two  lines.  They  are  usually  a  little  salient. 
By  means  of  local  and  general  treatment  these  lesions  may  be  removed, 
but  they  are  often  very  obstinate  and  persistent. 

Mucous  patches  of  the  tongue  are  not  infrequent,  and  are  found 
chiefly  at  its  tip  or  on  its  sides.  They  are  more  or  less  annoying  or 
painful,  and  in  smokers  and  persons  suffering  from  indigestion  they 
show  a  tendency  to  become  chronic  and  to  relapse  in  an  exasperating 
manner.     They  may  be  complicated  by  general  lingual  hyperemia. 

As  a  result  of  erythema  and  mucous  patches  of  the  tongue,  this 
organ  becomes  the  seat  of  fissures  which  are  developed  either  over  the 
dorsum  or  on  the  sides.  On  the  dorsum  of  the  tongue  these  fissures  are 
irregular  and  sinuous  in  shape,  while  on  the  sides  and  at  the  tip  they 
are  in  general  vertically  placed.  Coexistent  with  this  fissuration  of 
the  tongue  there  is  usually  mild  or  severe  epithelial  hyperplasia. 

These  lesions  are  obstinate  in  their  course,  and  they  present  de- 
cided evidence  of  being  of  epithelial  structure.  They  have  been 
variously  called  psoriasis,  ichthyosis  of  the  tongue,  and  leukoplakia. 
When  they  begin  in  the  secondary  period  it  is  usually  not  difficult  to 
establish  the  fact  that  they  originated  in  a  syphilitic  soil.  But  when 
they  develop  late  in  the  infection  there  may  be  some  doubt  as  to  their 
etiology.  These  lesions  belong  to  the  class  of  parasyphilitic  manifesta- 
tions, which  are  usually  processes  or  conditions  resulting  from  irrita- 
tive changes  left  by  the  original  syphilitic  inflammation.  They  are  the 
outcome,  but  not  the  essential  derivatives,  of  syphilitic  infection. 

These  lingual  lesions  are  very  prone  to  lead  to  epitheliomatous  degen- 
eration, hence  their  bearers  are  always  in  jeopardy. 

Treatment. — The  treatment  of  mucous  patches  and  of  the  milder 
forms  of  epithelial  hyperplasia  of  the  tongue  is  similar  to  that  of 
mucous  patches  of  the  mouth. 

In  the  obstinate  cases  of  fissures  a  gargle  of  bichloride  of  mercury 
in  water,  1  :  1000,  is  sometimes  very  beneficial.  In  some  cases  these 
lesions  require  active  but  carefully  applied  cauterization,  either  with 
equal  parts  of  carbolic  acid  and  glycerin  or  nitrate  of  silver  and  water, 
even  as  high  as  10  per  cent.  Strong  applications  should  only  be  made 
at  intervals  of  several  days.  In  the  interim  mild  and  astringent  solu- 
tions of  alum  or  tannin  may  be  used. 


AFFECTIONS  OF  THE  NOSE.  569 

For  epithelial  plaques  it  may  be  necessary  to  apply  liquid  carbolic 
acid  or  a  solution  of  caustic  potassa  (sj  to  sj  water).  These  cases  sorely 
tax  the  patience  of  the  afflicted  person  and  of  the  surgeon. 

In  all  cases  of  syphilitic  inflammation  of  the  tongue  it  is  most  im- 
portant that  every  source  of  irritation  shall  be  removed. 

Internal  treatment  has  no  influence  whatever  upon  the  psoriatic  or 
ichthyotic  patches  of  the  tongue. 

AFFECTIONS  OF  THE  NOSE. 

The  pituitary  membrane  may  be  the  seat  of  erythema,  superficial 
ulcerations,  and  mucous  patches,  which  give  rise  to  symptoms  resembling 
those  of  an  ordinary  catarrh.  Besides  these  lesions,  in  some  cases  an 
adenoid  tissue  is  developed,  which  gives  much  trouble  and  annoyance 
by  stopping  up  the  nasal  passages.  Sometimes  an  ulcer  may  be  seen 
just  within  the  nasal  orifice,  surrounded  by  swollen  mucous  membrane 
and  rendering  the  alae  nasi  tender  upon  pressure.  Plugs  of  inspissated 
mucus,  mixed  with  blood  and  pus,  which  obstruct  the  passages,  are  from 
time  to  time  discharged.  The  nasal  secretion  is  more  abundant  and 
more  purulent  when  ulcerations  or  mucous  patches  exist.  In  the  absence 
of  other  lesions  of  syphilis  upon  the  skin  or  elsewhere  the  character  of 
the  nasal  affections  may  be  suspected  only  because  of  their  persistence. 

Treatment. — In  treating  erythematous  exulcerous  conditions, 
mucous  patches,  and  adenoid  inflammation  in  the  nose  it  is  of  prime 
importance  not  to  use  strong  stimulating  applications,  except  under 
certain  restrictions.  The  parts  should  be  sprayed  several  times  a  day 
with  Dobell's  solution.  The  very  mild  solution  of  nitrate  of  silver 
(gr.  j  to  sviij  water)  may  be  used,  and  very  frequently  insufflations  of 
equal  parts  of  iodoform  and  boric  acid  are  very  beneficial.  In  all 
cases,  as  a  rule,  an  active  internal  treatment  should  be  ordered. 

AFFECTIONS  OF  THE    LARYNX. 

In  the  secondary  stage  the  larynx  may  be  attacked  by  (1)  erythema, 
(2)  superficial  ulcerations,  (3)  mucous  patches,  (4)  chronic  inflammation, 
with  hypertrophy  of  the  mucous  membrane  and  vegetations. 

Erythema. 

Erythema  of  the  larynx,  unless  it  be  very  acute  and  attended  by 
oedema,  may  be  so  slight  as  to  attract  no  attention,  the  only  symptoms 
being  slight  huskiness  of  the  voice  and  moderate  catarrh.  No  doubt 
it  occurs  during  early  skin  eruptions,  and  it  is  frequently  developed 
at  more  advanced  stages,  either  independently  or  in  connection  with 
deep  laryngeal  lesions.  There  may  be  nothing  in  the  appearance  of 
the  affection  to  distinguish  it  from  a  simple  catarrh.     It  occurs  either 


570  SYPHILITIC  AFFECTIONS  OF  VARIOUS  MUCOUS  MEMBRANES. 

in  patches,  which  give  the  mucous  membrane  a  mottled  appearance,  or 
it  may  be  limited  to  certain  regions,  or  it  may  be  diffuse,  the  lining  of 
the  larynx  having  a  uniform  dusky-red  hue.  There  may  be  superficial 
erosions  of  the  mucous  membrane. 

Superficial  Ulcerations. 

The  superficial  ulcerations  observed  in  laryngeal  syphilis  involve 
only  the  mucous  membrane.  They  may  affect  phonation  to-  some  ex- 
tent, but  are  generally  very  sluggish,  persisting  with  slight  change  for 
an  indefinite  period.  Their  margins  are  well  defined,  quite  regular,  and 
very  slightly  elevated  above  the  surrounding  level.  The  surface  of  the 
ulcers  is  usually  concealed  by  a  layer  of  tenacious  secretion.  Fre- 
quently general  erythema  of  the  mucous  membrane  coexists. 

When  seated  on  parts  exposed  to  irritation,  either  in  respiration  or 
in  phonation,  mucous  patches  of  the  larynx  are  prominent  with  ragged 
margins,  forming  what  are  known  as  condylomata  ;  in  other  regions 
they  are  flatter  and  the  ulceration  is  more  sharply  cut.  Their  surface 
is  covered  by  a  scanty  viscid  secretion.  The  removal  of  this  film  exposes 
a  red,  excoriated  surface  in  striking  contrast  with  the  paler  hue  of  the 
surrounding  mucous  membrane. 

Chronic  inflammation  of  the  larynx  is  very  persistent,  and  commonly 
leads  to  thickening  or  hypercemia  of  the  mucous  membrane. 

Treatment. — The  early  efflorescences  in  the  larynx  usually  disap- 
pear quite  promptly  under  the  influence  of  internal  treatment.  If  they 
are  obstinate,  they  usually  yield  rapidly  to  the  nitrate-of-silver  spray 
(gr.  j-iv  to  §vij  water). 

Deeper  lesions  should  be  treated  by  occasional  moderately  strong 
cauterization  (nitrate  of  silver  or  carbolic  acid),  followed  by  spraying 
with  Dobell's  solution.  When  there  is  ulceration,  insufflation  of  equal 
parts  of  iodoform  and  boric  acid  is  required. 

MUCOUS  PATCHES  OF  THE  GENITAL  ORGANS. 

The  most  frequent  seat  of  mucous  patches  in  men  is  around  the  anus 
and  within  the  mouth,  and  in  women,  upon  the  vulva.  It  has  been 
asserted  that  they  are  much  more  frequent  in  the  latter  than  in  the 
former  sex,  but  the  difference  is  probably  not  so  great  as  has  been 
supposed.  There  is  certainly  no  more  common  symptom  in  male 
patients  affected  with  syphilis.  They  are  also  present  in  most  cases 
of  hereditary  syphilis  in  infants,  and,  in  consequence  of  the  moist  con- 
dition of  the  integument  at  this  early  stage,  are  not  confined  to  the 
regions  above  mentioned,  but  may  be.  scattered  over  the  whole  surface 
of  the  body,  especially  the  nates  and  thighs. 

The  development  of  mucous  patches  is  everywhere  favored  by  inat- 


CONDYLOMATA   LATA.  571 

tention  to  cleanliness,  and  in  the  mouth  by  the  use  of  tobacco,  either  by 
smoking  or  chewing  :  in  men  who  are  habituated  to  these  practices  they 
constitute  one  of  the  most  persistent  and  troublesome  symptoms  we  have 
to  deal  with,  and  in  dirty  prostitutes  of  the  lower  class  they  are  equally 
abundant  and  obstinate  about  the  genital  organs. 

Mucous  patches  vary  in  appearance  according  to  their  situation. 
The  chief  points  of  difference  are  found  between  those  seated  upon 
the  external  integument  and  those  upon  membranes  which  are  strictly 
mucous. 

The  former,  which  are  met  with  for  the  most  part  around  the  anus 
and  genital  organs  in  the  two  sexes,  consist  of  rounded  disks,  either 
single  or  aggregated,  of  a  reddish  or  grayish  color,  granulated  and  elevated 
to  the  height  of  about  a  line  above  the  integument,  upon  which  they 
appear  to  be  superimposed  like  a  number  of  cones  laid  upon  the  part. 
They  then  receive  the  name  of  condylomata.  Their  appearance  is  so 
peculiar  that  when  once  seen  they  are  readily  recognized. 

CONDYLOMATA  LATA. 

The  mode  of  development  of  condylomata  lata  is  as  follows  :  A  red 
spot  first  appears  upon  the  skin,  and  a  slight  effusion  takes  place  beneath 

Fig.  138. 


Condylomata  lata  of  the  vulva  and  anal  region.    On  the  latter  they  present  a  papillomatous  01 

vegetating  appearance. 


572    SYPHILITIC  AFFECTIONS   OF   VARIOUS  MUCOUS  MEMBRANES. 

the  epidermis — sufficient  to  loosen  it  from  the  derma,  but  not  to  raise  it 
in  the  form  of  a  vesicle  or  bulla ;  the  epidermis  is  removed  by  friction 
or  falls  off,  and  exposes  a  raw  surface,  upon  which  a  moist  grayish  pelli- 
cle is  formed ;  the  surface  is  elevated  by  hypertrophy  of  the  superficial 
layers  of  the  skin,  and  gives  rise  to  the  broad,  flat,  wart-like  disks  re- 
ferred to  above. 

In  Fig.  138  condylomata  lata  situated  around  the  vulva  and  anus  are 
graphically  portrayed.  In  Fig.  139  condylomata  lata  of  the  anus  of  a 
man  are  well  shown. 

Fig.  139. 


Condylomata  of  the  anus  with  tendency  to  vegetations. 

Condylomata  upon  the  vulva  are  generally  elevated  and  of  a  reddish 
color.  Those  that  occur  within  the  vagina  and  upon  the  cervix  uteri 
more  closely  resemble  mucous  patches  upon  the  external  integument 
than  those  situated  upon  other  mucous  membranes,  as,  for  instance, 
within  the  buccal  cavity. 

Treatment. — In  all  cases  of  mucous  patches  or  of  condylomata  lata 
on  or  about  the  genitals  an  energetic  systemic  treatment  should  be 
adopted.  Locally,  the  prime  essentials  are  absolute  cleanliness,  and  a 
dry  condition,  and  the  covering   of  the   parts  by  some   protective  sub- 


CONDYLOMATA   LATA.  573 

stance,  or  the  interposition  of  some  absorbent  material,  cotton  or  gauze, 
between  coapted  surfaces.  Black  or  yellow  wash,  applied  on  absorbent 
cotton,  is  very  efficacious. 

When  these  lesions  are  very  large  and  papillomatous,  they  may  be 
lightly  and  carefully  touched  with  a  solution  of  nitrate  of  silver  (sj  to 
water  sj),  with  chloroacetic  acid,  carbolic  acid,  or,  in  very  exuberant 
cases,  with  the  acid  nitrate  of  mercury.  After  these  active  cauterizations 
the  parts  should  be  well  washed  and  dried,  and  then  dusted  with  some 
inert  powder,  over  which  a  layer  of  absorbent  cotton  should  be  placed. 
Aristol,  resorcin,  or  calomel  in  combination  with  starch  or  boric  acid 
forms  a  pleasant  and  effective  application  for  continual  use. 

In  women  especially  the  parts  should  be  kept  extremely  clean  and 
dry.  Hot  intravaginal  injections  of  bichloride  of  mercury  and  water 
(1  :  5000  or  1 :  3000)  should  be  used  several  times  daily.  The  genitals 
should  then  be  dried  and  dusted  with  equal  parts  of  calomel  and  starch, 
and  an  abundance  of  absorbent  cotton  should  be  applied  by  means  of  a 
bandage  if  possible.  In  some  of  these  cases  active  cauterization,  prefer- 
ably with  carbolic  acid,  should  be  used. 


CHAPTER   XXXIII. 

SYPHILITIC  AFFECTIONS  OF  THE  HAIR. 

Alopecia  is  one  of  the  most  common  symptoms  of  syphilis.  By 
reason  of  its  prominence  and  of  its  compromising  character  it  is  the 
source  of  constant  worry  and  annoyance  to  its  bearer.  It  varies  from 
slight  to  almost  complete  loss  of  hair,  which  is  rarely  permanent,  and  its 
course  may  be  rapid  or  chronic.  It  is  attended  by  no  subjective  symp- 
toms, such  as  heat  or  itching,  and  in  most  cases  there  are  no  marked 
lesions  of  the  scalp,  while  in  other  cases  the  hair-follicles  may  be  attacked 
by  macules,  papules,  pustules,  or  ulcers.  The  eyebrows,  the  beard,  and 
moustache,  the  hair  of  the  pubes  and  axillae,  may  also  be  involved.  The 
eyelashes  are  seldom  attacked,  except  by  ulcerative  lesions,  and  alopecia 
never  exists  elsewhere  without  affecting  the  scalp.  These  may  be  called 
the  essential  alopecise,  while  loss  of  hair  due  to  destructive  or  inflam- 
matory lesions  is  a  secondary  form. 

There  are  two  varieties  of  syphilitic  alopecia — one  consisting  of  a 
simple  thinning  or  more  or  less  complete  shedding  of  the  hair,  and  the 
other  of  loss  of  the  hair  in  tolerably  circumscribed  patches.  They  both 
occur  with  about  equal  frequency. 

The  first  form  of  alopecia  begins  rather  abruptly,  and  on  each  comb- 
ing many  hairs  usually  come  away.  On  the  scalp  the  result  of  this 
alopecia  is  generally  striking,  but  it  may  be  so  slight  as  to  pass  unnoticed, 
the  hair  merely  being  thinned.  The  hair  may  be  lost  in  one  or  more 
patches,  which  vary  in  size  and  occur  without  symmetry  or  order ;  they 
may  be  as  large  as  the  palm  of  one's  hand,  and  several  may  fuse  together. 
Their  outline  is  irregular,  and  they  show  no  tendency  to  assume  a  circu- 
lar form.  The  surface  of  the  patches  is  rather  dry  and  somewhat  scaly  ; 
the  follicles  are  quite  prominent,  and  scattered  irregularly  may  be  a  few 
long  hairs,  sometimes  one  or  more  tufts,  and  minute  hairs.  The  surface 
of  the  scalp  is  dry  and  presents  a  few  furfuraceous  scales.  In  patients 
who  have  been  subject  to  seborrhoea  capitis — or,  as  it  is  generally  known, 
pityriasis  capitis — this  condition  is  often  much  more  marked. 

Patients,  especially  men,  who  have  suffered  from  this  form  of  bald- 
ness not  infrequently  get  into  a  state  of  mind  in  which,  after  the  cessa- 
tion of  the  fall,  nothing  can  convince  them  that  the  affection  does  not 
yet  continue.  They  come  regularly  with  their  complaints  and  sorrows, 
and  often  vainly  pass  their  fingers  through  their  hair,  hoping  to  bring 
away  a  few  with  which  to  convince  the  surgeon  that  the  affection  is  still 
574 


SYPHILITIC  AFFECTIONS  OF  THE  HAIR. 


575 


active.  In  most  cases  this  delusion  is  dispelled  after  a  time.  In  Fig. 
140  this  form  of  alopecia  is  well  shown.  The  general  diffuse  shedding 
of  the  hair  of  the  scalp  is  typically  portrayed.  In  this  case  there  was 
loss  of  eyebrows  and  eyelashes. 


Fig.  140. 


The  diffuse  shedding  form  of  syphilitic  alopecia. 


The  second  or  patchy  form  of  syphilitic  alopecia  presents  such 
striking  features  that  when  it  is  once  seen  it  is  thereafter  readily  recog- 
nized by  the  surgeon.  The  surface  of  the  scalp  presents  a  moth-eaten 
or  mangy  appearance.  The  hairs  are  generally  dry  aixl  lustreless,  giving 
the  appearance  of  malnutrition.  The  bald  patches  are  of  irregular 
round  or  oval  outline,  and  from  fusion  they  become  gyrate.  The  scalp 
is  dry,  scaly,  and  generally  unhealthy  in  appearance.  The  hair- follicles 
are  prominent,  and  from  some  of  them  stumpy  hairs  protrude. 

This  form  of  alopecia  (admirably  portrayed  in  Fig.  141)  is  usually 
most  severe  on  the  back  and  upper  portions  of  the  head,  and  less  so  on 
the  sides  and  frontal  region.      It  runs  a  chronic  sluggish  course. 

The   hair- follicles  may  be   involved  by  erythematous  spots,  papules, 


576 


SYPHILITIC  AFFECTIONS   OF  THE  HAIR. 


or  pustules  coincidently  with  a  general  eruption.  In  such  cases  the  loss 
of  hair  is  generally  slight  and  scattered.  The  arch  of  the  eyebrows  may 
be  interrupted  by  the  fall  of  a  few  hairs  or  may  be  totally  destroyed, 
giving  the  patient  a  very  peculiar  appearance.     In  the  beard,  in  the 


Fig.  141. 


The  moth-eaten  furm  of  syphilitic  alopecia. 


axilla?,  and  upon  the  pubes  the  loss  of  hair  may  also  be  partial,  complete, 
or  in  patches. 

Syphilitic  alopecia  is  peculiar  to  the  secondary  period,  and  generally 
begins  about  the  third  month,  at  the  decline  of  the  earlier  secondary 
symptoms.  It  may  occur  at  any  time  before  the  end  of  the  second  year, 
and  is  very  frequently  associated  with  cachexia. 

When  ulcerative  changes  occur  in  the  follicles,  or  when  pustules 
attack  the  scalp,  and  sometimes  even  when  erythematous  spots  and 
papules  occur,  the  papilla?  may  be  destroyed  and  the  follicles  become 
obliterated,  permanent  baldness  resulting.  This  happens  in  a  marked 
degree  in  connection  with  late  tubercles  and  gummatous  ulcers. 


SYPHILITIC  AFFECTIONS   OF   THE  HAIR.  577 

Diagnosis. — The  diagnosis  of  syphilitic  alopecia  is  to  be  made  from 
pityriasis  capitis  (seborrhoea),  senile  baldness,  and  alopecia  areata.  The 
suddenness  of  invasion  and  the  generally  marked  character  of  the  bald- 
ness in  syphilitic  alopecia  and  its  non-inflammatory  course  are  in  marked 
contrast  with  the  chronic  course  and  the  scaly  and  somewhat  pruritic 
condition  of  pityriasis  capitis.  Moreover,  the  suspicion  of  syphilis  is 
confirmed  by  the  history  of  the  case  and  the  discovery  of  other  specific 
lesions. 

Senile  alopecia — incorrectly  so  called,  since  it  usually  begins  in 
middle  life — extends  backward  from  the  forehead  or  begins  at  the 
vertex,  and  is  wholly  unlike  the  syphilitic  affection.  Moreover,  the 
scalp  is  smooth  and  shiny,  and  the  follicular  openings  are  no  longer 
visible. 

Alopecia  areata  is  much  more  common  in  children  than  in  adults,  and 
occurs  in  round,  oval,  or  serpiginous  patches,  the  hair  on  other  parts  of 
the  scalp  being  preserved.  The  surfaces  of  the  patches  are  very  smooth 
and  polished,  and  of  a  yellowish- white  color ;  they  are  not  scaly,  and 
are  completely  destitute  of  hair. 

The  prognosis  of  syphilitic  alopecia  is,  in  general,  good.  In  some 
cases  the  loss  of  hair  is  so  extensive  and  its  renewal  so  slow  that  per- 
manent baldness  seems  to  be  inevitable.  The  main  points  upon  which 
to  base  the  prognosis  are  the  extent  of  the  baldness,  its  duration,  and 
the  patient's  general  health.  If  the  affection  has  been  severe  and  has 
existed  for  some  time,  if  treatment  has  been  neglected  and  incomplete, 
and  if  cachexia  has  taken  place,  the  prognosis  must  be  very  guarded. 

Treatment. — Cases  of  syphilitic  alopecia  call  for  a  vigorous  local 
and  constitutional  treatment.  If  possible,  inunctions  should  be  used 
on  the  neck  and  especially  the  upper  parts  of  the  body.  The  hair  of  the 
scalp  should  be  cut  off  quite  close,  and,  if  expedient,  should  be  shaved, 
and  frequent  shampooing  is  very  beneficial.  Every  day  the  affected 
parts,  and  indeed  the  whole  scalp,  should  be  well  rubbed  with  an 
ointment  composed  of  white  precipitate  (30  grains)  and  cold  cream  (1 
ounce).  This  application  may  be  made  at  night.  The  parts  should  be 
well  washed  with  soap  and  water  in  the  morning,  and  twice  during  the 
day  they  should  be  vigorously  rubbed  with  a  bichloride  solution  (1 :  500 
or  1  :  250). 
37 


CHAPTER    XXXIV. 

SYPHILITIC  AFFECTIONS  OF  THE  NAILS. 

Syphilitic  affections  of  the  nails  are  of  two  varieties  :  in  one, 
called  onychia,  the  disease  begins  primarily  in  the  nails  themselves  ;  and 
in  the  other,  called  perionychia,  it  begins  in  their  vicinity  and  involves 
them  secondarily.  Their  course  is  chronic,  and  may  be  mild  or  severe 
and  destructive.  They  generally  appear  within  the  first  two  years  fol- 
lowing syphilitic  infection,  but  their  invasion  may  occur  much  later. 

In  syphilitic  onychia  the  changes  may  be  dry  and  confined  to  the  nail- 
substance  or  the  nail  may  be  separated  from  its  bed. 

In  the  dry  form,  onychia  sicca,  the  nail  gradually  loses  its  lustre  and 
transparency  at  its  free  edge  and  assumes  a  dull-yellow  color  ;  some- 
times the  disease  is  limited  by  a  distinct  line  of  demarcation  or  the 
whole  nail  may  be  involved.  The  edge  of  the  nail  becomes  thickened 
and  brittle,  readily  cracks,  and  may  be  deeply  serrated  (Fig.  142). 

Fig.  142. 


Dry  onychia. 

Its  surface  is  rough,  and  presents  shallow,  longitudinal  fissures  and 
minute  depressions,  in  which  dirt  collects.  In  some  cases  the  morbid 
process  begins  as  a  small  pinkish,  perhaps  scaly,  spot  limited  to  one 
segment  of  the  reflection  of  the  integument,  just  at  the  sulcus.  From 
this  focus  the  chronic  inflammatory  process  extends  both  along  the  sul- 
578 


SYPHILITIC  AFFECTIONS   OF  THE  NAILS.  579 

cus  and  into  the  nail,  which  it  literally  destroys.  The  epidermis  under 
and  beyond  the  free  margin  is  usually  thickened  and  scaly.  Very  often 
there  is  but  slight  inconvenience  from  the  disease,  and  the  deformity 
may  be  remedied  by  careful  paring  of  the  nail.  In  some  cases,  how- 
ever, the  process  becomes  so  intense  that  the  whole  nail  is  converted 
into  an  irregular  rough  plate,  causing  great  deformity  of  the  hands? 
which  is  very  annoying  to  patients. 

Treatment  results  in  the  gradual  pushing  forward  of  the  diseased 
portion,  leaving  a  healthy  nail. 

There  is  also  an  hypertrophic  onychia,  in  which  the  thickening  of  the 
nail  is  excessive.  It  involves  the  nails  of  the  fingers  more  frequently 
than  those  of  the  toes,  and  usually  attacks  more  than  one  nail.  This 
hypertrophic  state  is  well  shown  on  the  nail  of  the  thumb  in  Fig.  142. 

There  is  also  an  affection  of  the  nails,  of  which  I  have  seen  several 
well-marked  instances  in  men  suffering  with  syphilitic  cachexia,  which 
seems  to  be  a  local  necrosis.  The  nail  becomes  opaque  and  whitish,  in 
spots  the  size  of  a  pinhead.  These  spots,  of  which  there  may  be  from 
two  or  three  to  ten,  are  formed  by  depressions  of  the  surface  of  the  nail, 
which  finally  reach  the  matrix,  leaving  minute  and  sharply  cut  holes. 
In  some  cases  the  necrosis  is  superficial,  and  the  whole  thickness  of  the 
nail  is  not  perforated.  When  this  occurs  the  nail  presents  much  the 
appearance  of  the  roughened  surface  of  a  thimble. 

Perionychia. — There  are  three  forms  of  perionychia — an  ulcerative, 
an  indolent  (which  is  usually  non-ulcerative),  and  a  diffuse  form. 

The  non-ulcerative  form  may  attack  the  entire  attached  margin  of 
the  nail  or  its  lunula  or  one  of  its  lateral  margins.  The  border  of  the 
nail,  to  the  width  of  about  one  line,  is  thickened  in  consequence  of 
specific  infiltration,  and  there  is  a  more  or  less  complete  papular  rim 
around  it.  The  color  is  dull  red,  which  pales  on  pressure,  and  the  sur- 
face is  slightly  scaly.  This  condition  may  persist  for  a  longtime,  until 
the  nail  becomes  of  a  dull  color  and  is  traversed  by  shallow  transverse 
furrows,  showing  impaired  nutrition.  As  a  result  of  pressure  or  irri- 
tation ulceration  may  occur  at  the  angle  of  reflection  of  the  skin,  and 
may  extend  beneath  the  nail,  which  is  finally  loosened  and  thrown  off. 

Ulcerative  perionychia  occurs  at  any  time  during  the  secondary 
period,  and  varies  greatly  in  severity.  It  may  begin  as  a  papule  or  a 
pustule  at  some  part  of  the  nail-margin,  or  a  small  ulceration  or  fissure 
at  the  lunula  is  the  change  first  noticed.  In  either  case  the  inflamma- 
tion gradually  increases,  and  ulceration  extends  along  the  sulcus  at  the 
attached  margin  of  the  nail.  The  process  may  be  limited  to  the  lunula 
or  to  a  portion  of  the  nail-border,  or  it  may  involve  the  entire  length 
of  the  sulcus.  When  the  lunula  is  invaded  the  affection  is  very  obsti- 
nate ;  the    base   of  the  nail  soon    loses  its  transparency   and  becomes 


580  SYPHILITIC  AFFECTIONS  OF  THE  NAILS. 

detached  to  the  extent  of  about  a  line.  The  ulceration,  which  extends 
under  the  nail  itself  and  may  be  for  a  time  inaccessible,  constantly 
secretes  an  offensive  pus.  The  whole  nail  may  be  gradually  under- 
mined, or  the  parts  may  be  denuded  to  a  limited  extent  by  destruction 
of  the  attached  margin. 

When  the  ulceration,  which  is  likely  to  be  particularly  intense  at  the 
lunula,  is  severe,  the  whole  matrix  becomes  involved,  and  after  the  nail 
has  been  thrown  off  it  presents  a  yellowish,  somewhat  pultaceous  surface, 
surrounded  by  the  swollen  and  ulcerated  nail-margin.  Soon  the  ulcera- 
tion shows  a  tendency  to  localize  itself  at  the  basal  margin,  while  the 
surface  of  the  matrix  becomes  covered  with  a  dirty-yellow,  firm,  and 
uneven  epithelial  tissue. 

If  the  base  of  the  nail  has  not  been  too  extensively  destroyed,  it  re- 
tains a  surprising  degree  of  reparative  power.  A  new  nail  appears  and 
covers  the  matrix,  unless  it  be  excessively  hypertrophied,  and  may  be 
quite  as  good  as  the  original  nail.  In  some  cases  a  perfect  nail  results 
only  after  several  renewals. 

In  persons  whose  hands  are  exposed  to  irritants  perionychia  may 
begin  under  the  free  edge  of  the  nail,  generally  of  the  index  or  middle 
finger.  Slight  pain  attracts  the  attention  of  the  patient,  and  he  finds  a 
brownish-red  crust  beneath  the  nail,  removal  of  which  exposes  an  ulcer 
extending  along  more  or  less  of  the  nail's  breadth. 

The  third  or  diffuse  form  of  perionychia  begins  as  a  hyperemia  which 
is  bright,  diffuse,  and  not  limited  to  the  nail.  For  two  or  three  weeks 
the  case  may  present  simply  a  reddened  condition  of  the  distal  portion 
of  the  affected  fingers.  There  may  be  no  pain  at  first.  In  this  very 
subacute  manner  the  bright  red  deepens  to  a  coppery  hue,  and  the 
affected  parts  become  swollen  and  bulbous  or  of  the  shape  of  an  Indian 
club,  due  to  syphilitic  inflammation  and  infiltration.  Coincidently  with 
the  intensification  of  the  disease  the  nails  become  affected  and  are  de- 
stroyed, seemingly  as  if  struck  by  a  blight. 

This  rapid  necrosis  is  peculiar  to  this  form  of  perionychia.  The  nail 
first  loses  its  color,  which  becomes  dull  and  dark,  then  its  attachment 
at  each  border  gives  way  first,  and  after  that  in  its  whole  extent  ulcera- 
tion with  the  formation  of  a  thick,  ill-smelling  pus  taking  place  beneath 
it.  The  nail  then  rapidly  becomes  considerably  swollen,  uneven,  and 
puckered,  and  of  a  black  and  green  color,  well  shown  in  Fig.  143. 

Separation  of  the  Nail. — Separation  of  the  nail  takes  place  not  in- 
frequently in  the  early  part  of  the  secondary  stage  of  syphilis,  and 
may  be  partial  or  complete.  The  process  may  be  so  insidious  and  it 
may  cause  so  little  inconvenience,  especially  with  careless  persons  and 
when  the  toe-nails  are  affected,  that  several  nails  may  fall  off  without 
attracting    the    notice   of  the   patient.     It    begins  at   the    free    border 


SYPHILITIC  AFFECTIONS  OF  THE  NAILS. 


581 


of    the    nail,    being    limited    at    first    to    a    portion    of    its    breadth 
(Fig-  143).  FlG.143. 


Diffuse  perionychia. 


It  gradually  extends  toward  the  base  of  the  nail,  involving  one- 
third  to  one-half  its  length,  and  possibly  its  entire  breadth.  In  neglected 
cases  the  whole  nail  may  be  affected  and  thrown  off.     The  diseased  por- 


Fig.  144. 


Separation  of  the  nails. 


tion  of  the  nail  assumes  a  greenish-brown  color,  and  the  matrix  beneath 
presents  more  or  less  healthy  granulations.  When  the  destruction  of 
the  nail  has  been  partial  the  healthy  portion  pushes  forward  and  covers 


582  SYPHILITIC  AFFECTIONS  OF  THE  NAILS. 

the  denuded  parts  :  when  it  has  been  complete,  an  entirely  new  nail  is 
formed.  Only  one  nail  may  be  affected,  or  several  may  be  involved 
simultaneously  or  in  succession,  those  of  the  hands  more  frequently  than 
those  of  the  feet.     (See  Fig.  144.) 

With  the  onset  of  the  nail-affections  pain  becomes  an  important  ele- 
ment in  the  case,  and  the  fingers  are  then  useless  for  any  function. 
The  imbedded  portion  of  these  appendages  is  the  one  which  gives  the 
most  trouble.  Here  the  destructive  process  is  usually  not  sufficiently 
great  to  cause  the  spontaneous  extrusion  of  the  nail,  and  this  sequestrum 
remains,  causing  severe  pain,  acting  as  a  foreign  body,  and  keeping  up 
the  ulcerative  process.  So  severe  may  be  the  inflammation  that  the 
forearm  and  arm  become  red,  swollen,  and  painful,  with  sympathetic 
implication  of  the  axillary  glands,  attended  by  high  fever,  malaise,  and 
much  suffering.  When,  however,  the  dead  nail  is  removed  and  appro- 
priate treatment  is  adopted,  the  coppery-red  phalanx  loses  its  tension, 
becomes  superficially  wrinkled,  and  of  a  purplish-red  color. 

All  forms  of  syphilitic  perionychia  are  very  chronic,  rarely  lasting 
less  than  one  or  two  months,  and  sometimes  continuing  a  year.  At 
first  they  may  cause  scarcely  any  inconvenience,  and  for  this  reason 
they  are  often  neglected. 

The  nails  of  the  fingers  and  of  the  toes  are  attacked  with  equal  fre- 
quency, those  most  used  and  most  exposed  being  the  most  liable.  In 
general,  only  one  finger  is  affected,  sometimes  a  finger  of  each  hand,  or 
two  fingers  of  the  same  hand,  either  simultaneously  or  more  commonly, 
in  succession.     In  some  cases  all  the  nails  become  affected. 

Diagnosis. — Chronic  eczema  and  psoriasis  of  the  hand  are  some- 
times followed  by  changes  in  the  nail  similar  to  those  of  syphilitic 
friable  onychia.  The  question  may  be  settled  by  the  previous  history 
of  the  case. 

I  have  seen  two  cases  of  separation  of  the  nail,  in  every  particular 
similar  to  that  produced  by  syphilis,  in  which  that  infection  did  not  exist. 

Ulcerative  perionychia  has  been  mistaken  for  the  initial  lesion  of 
syphilis. 

Severe  perionychia  resembling  the  syphilitic  form  is  sometimes  seen 
in  broken-down  and  cachectic  subjects.  Its  occurrence  should  always 
excite  the  suspicion  of  syphilis. 

Prognosis. — The  prognosis  of  friable  and  of  hypertrophic  onychia 
is  good,  since  its  course  is  generally  mild  and  transient.  The  same  is 
true  when  separation  of  the  nails  occurs,  the  morbid  condition  being 
soon  relieved  by  proper  treatment. 

The  ulcerative  forms  are  always  troublesome  and  often  very  painful 
affections,  and  the  prognosis  should  always  be  guarded.  The  earlier 
separation  of  the  nail  occurs  and  the  focus  of  the  disease  at  the  base  of 


SYPHILITIC  AFFECTIONS  OF  THE  NAILS.  583 

the  nail  is  reached  by  local  applications,  the  sooner  may  relief  be  ex- 
pected. New  and  comely  nails  sometimes  develop  even  after  prolonged 
and  intense  basal  ulceration.  In  nearly  all  cases  where  the  perionychia 
is  lateral  or  at  the  free  border  of  the  nail  a  perfect  nail  may  be  pre- 
dicted. 

The  growth  of  the  new  nail  is  very  slow,  and  the  spiculse  at  the 
edges  and  the  uneven  plates  which  often  form  on  the  surface  of  the 
matrix  are  important  indications  of  retention  of  the  nail-producing 
power.  The  new  nail  is  often  imperfect  at  first,  being  ridged  and  irreg- 
ular, and  it  is  sometimes  permanently  shorter  than  the  old  one. 

Treatment. — Active  internal  treatment  is  required  in  all  forms  of 
syphilitic  aifections  of  the  nails. 

Friable  onychia  calls  for  no  other  local  treatment  than  careful  trim- 
ming of  the  nails  and  prevention  of  irritation.  The  severe  forms  of 
dry  onychia  are  often  very  intractable,  and  require  active  local  treat- 
ment. The  fingers  should  be  soaked  twice  daily  in  hot  bichloride  solu- 
tion (1  :  1000),  and  mercurial  ointment  should  be  well  rubbed  in  and 
kept  on  the  parts. 

In  case  of  separation  of  the  nail  exposure  of  the  matrix  and  the 
application  every  day  or  two  of  liquor  potassae,  followed  by  the  use  of 
an  ointment  composed  of  one  part  of  mercurial  and  two  parts  of  diach- 
ylon ointment,  will  arrest  the  disease.  The  simple  form  of  perionychia 
may  be  cured  by  the  use  of  this  ointment. 

In  ulcerative  perionychia  the  diseased  surface  should  be  exposed  as 
soon  as  possible,  and  cauterized  with  nitric  acid  or  a  strong  solution  of 
nitrate  of  silver,  allaying  inflammatory  reaction  with  water  dressings. 
Subsequently  iodoform  or  powdered  nitrate  of  lead  may  be  applied,  and 
the  phalanx  be  enveloped  in  diachylon  ointment.  The  profuse  granu- 
lations of  the  matrix  may  require  the  use  of  a  strong  solution  of  caustic 
potassa  (oj— 3ij  or  iv  to  water  sj).  Prolonged  immersion  of  the  hand 
in  very  warm  bichloride  solution  (1  :  1000)  diminishes  the  swelling  and 
removes  the  secretions.  The  application  of  a  bandage  over  the  oint- 
ment, India-rubber  finger-stalls,  or  gutta-percha  tissue,  may  serve  to 
reduce  the  swelling.  Care  must  be  taken  to  apply  the  pressure  grad- 
ually. 

In  addition,  zinc  and  belladonna  ointments  or  Goulard's  extract  may 
be  used  to  meet  special  indications. 


CHAPTER   XXXV. 

SYPHILITIC  AFFECTIONS  OF  THE  EYE. 

With  the  great  variety  of  tissues  represented  in  the  eye  and  its 
appendages,  the  ocular  manifestations  of  syphilis  are  manifold.  They 
are  met  with  in  every  stage  of  the  disease,  ranging  from  the  initial 
lesion  on  the  lid  to  the  late  affections  of  the  nerves.  Ocular  manifesta- 
tions, moreover,  are  found  in  a  considerable  percentage  of  cases  of 
syphilis,  and  frequently  they  are  the  first  symptoms  of  the  disease  to 
lead  the  patient  to  seek  medical  advice.  Not  infrequently  they  are  the 
most  serious  manifestations  that  occur.  Therefore,  a  consideration  of 
the  eye  symptoms  present  or  past  is  often  of  essential  importance  in 
establishing  the  diagnosis  of  syphilis. 

LIDS  AND  CONJUNCTIVA. 

When  a  secondary  eruption  appears  on  the  forehead  or  nose  the 
upper  lids  are  usually  involved,  and  a  falling  of  the  lashes  may  accom- 
pany alopecia  of  the  scalp.  A  simple  catarrhal  conjunctivitis  is  common 
at  this  time.  Later,  papules  and  tubercles  may  appear  on  the  lids,  or, 
more  rarely,  on  the  conjunctiva,  and  by  breaking  down  may  form  shallow 
ulcers. 

Still  later,  true  gummata  may  develop  as  single  or  multiple 
dusky-red  tumors,  much  resembling  the  simple  tumors  of  the  Mei- 
bomian glands,  but  being  movable  over  the  tarsus.  They  may  run  a 
chronic  course,  or  they  may  develop  quickly  with  inflammatory  signs 
and  rapidly  break  down.  There  is  then  formed  either  on  the  cutaneous 
or  the  mucous  surface  of  the  lid  a  deep,  sloughing  ulcer  with  reddish, 
notched  margins,  which  is  sometimes  confounded  with  lupus  or  epithe- 
lioma, particularly  as  the  auricular  glands  are  enlarged  in  all  these  con- 
ditions. In  its  cicatrization  the  gummous  ulcer  leads  to  great  distor- 
tion of  the  lid. 

Finally,  the  dense  connective  tissue  of  the  tarsus  of  the  upper  lids 
may  undergo  a  chronic,  diffuse,  gummous  infiltration,  known  as  syphilitic 
tarsitis.  This  is  often  accompanied  by  thickening  of  the  mucosa  and 
oedema  of  the  subcutaneous  tissue,  so  that  the  entire  lid  is  uniformly 
swollen,  and  from  its  increased  weight  droops  down  over  the  pupil. 

LACHRYMAL  APPARATUS  AND  ORBIT. 

Catarrhal  and  purulent  inflammations  of  the  lachrymal  sac  (dacryo- 
cystitis)  are   not  infrequently   seen   in    both    hereditary  and    acquired 

584 


LACHRYMAL  APPARATUS  AND   ORBIT.  585 

syphilis,  and  are  brought  about  by  any  permanent  obstruction  to  the 
passage  of  tears  down  the  nasal  duct.  Such  obstruction  is  usually  due 
to  occlusion  of  the  nasal  opening  of  the  duct  from  swelling  or  cicatriza- 
tion of  the  nasal  mucosa,  or  to  disease  of  the  bony  wall  of  the  canal 
higher  up. 

Lachrymal  affections  are  seen  in  persons  with  hereditary  syphilis  in 
whom  the  nose  is  much  sunken  and  malformed,  and  in  persons  with 
acquired  syphilis  in  whom  there  is  necrosis  of  the  lateral  bones  of  the 
nose. 

Operative  measures  to  relieve  lachrymal  obstruction  are  now  less 
frequently  employed  than  formerly,  and  probing  is  not  so  confidently 
resorted  to. 

Phlegmonous  inflammation  of  the  lachrymal  sac  requires  early  inci- 
sion, and  annoying  chronic  purulent  inflammations  may  necessitate  oblit- 
eration of  the  cavity  of  the  sac  by  the  use  of  caustics,  or  the  complete 
extirpation  of  the  sac. 

The  syphilitic  affections  of  the  orbit  are  usually  primarily  periosteal, 
and  they  arise  late  in  the  course  of  the  disease.  This  periostitis  varies 
greatly  in  nature,  location,  course,  and  complications.  It  may  be  dis- 
tinctly gummous  and  nodular,  or  it  may  be  diffuse.  The  margins  of  the 
orbit  are  more  frequently  affected  than  the  deeper  parts.  The  affection 
when  due  to  syphilis  is  more  frequently  chronic  than  acute,  the  acute 
cases  mostly  being  traumatic.  Starting  in  the  periosteum,  the  inflamma- 
tion at  times  involves  also  the  cellular  tissue  of  the  orbit,  giving  rise  to 
phlegmon — a  serious  condition  which  may  injure  the  optic  nerve,  or 
destroy  the  eye,  or  even  lead  to  a  purulent  meningitis  that  is  fatal.  On 
the  other  hand,  a  primary  periostitis  at  times  affects  the  nutrition  of  the 
underlying  bone,  leading  to  caries  or  necrosis  of  the  orbital  walls,  with 
the  formation  of  fistulous  tracts  which  in  their  cicatrization  distort  the 
lids  and  leave  ugly  indrawn  scars, 

AVhen  the  periostitis  is  near  the  margin  of  the  orbit  there  will  be 
pain  and  tenderness  on  pressure,  oedema  of  the  adjacent  lid,  chemosis 
of  the  bulbar  conjunctiva,  and  perhaps  displacement  of  the  eyeball  in 
a  direction  away  from  the  inflamed  area.  When  the  periostitis  is  deep 
in  the  orbit  there  will  be  oedema  of  both  lids,  chemosis  of  the  con- 
junctiva, and  exophthalmos  with  diminished  mobility  of  the  eye  and 
pain,  and,  at  times,  also,  optic  neuritis  and  paralysis  of  the  muscles  of 
the  eye  from  pressure  on  the  orbital  nerves. 

The  treatment  of  suppurative  cases  is  deep  incision  of  the  orbit 
with  a  narrow-bladed  knife  as  soon  as  fluctuation  can  be  obtained. 
Active  constitutional  treatment  is  always  indicated,  and,  when  bone  is 
diseased,  an  earnest  attempt  is  to  be  made  to  remove  the  affected  por- 
tions. 


586  SYPHILITIC  AFFECTIONS  OF  THE  EYE. 

SOLERA  AND  CORNEA. 

The  affections  of  the  sclera  and  the  deep  non-ulcerous  affections  of 
the  cornea  are  caused  by  endogenous  infection,  and  are  due  to  syphilis, 
rheumatism,  gout,  and  the  like.  Rarely  occurring  in  the  course  of 
acquired  syphilis,  they  are  very  frequent  in  the  hereditary  variety,  and 
hence  when  due  to  syphilis  these  affections  usually  appear  in  early  life. 

Scleritis  is  generally  divided  into  episcleritis,  and  true  or  deep  seleri- 
tis.  Episcleritis  usually  occurs  late  in  life,  and  is  not  often  of  syphilitic 
origin.  It  appears  as  a  single  patch  or  elevated  nodule  of  infiltration 
in  the  episcleral  tissue  near  the  cornea.  The  affection  is  usually  acute, 
and  it  runs  its  course  without  leaving  any  trace,  but  it  is  prone  to  recur. 

True  scleritis  is  a  chronic  affection  of  early  life,  usually  associated 
with  and  dependent  upon  chronic  cyclitis,  and  leading  often  to  deep 
infiltrations  of  the  cornea.  There  may  be  a  diffuse  thickening  of  the 
sclera  over  a  considerable  area,  or  there  may  be  several  nodular  thicken- 
ings. The  affected  area  lies  near  the  cornea  and  is  of  a  deep  purple 
color.  The  infiltration  leads  to  a  softening  of  the  component  fibres  of 
the  sclera,  which  break  down,  so  that  the  sclera  in  time  becomes  thin 
and  translucent  and  the  uveal  pigment  shows  through.  Later,  the 
thinned  area  may  yield  to  the  intra-ocular  pressure,  particularly  if  this 
has  been  increased  by  uveal  complications,  and  an  ectasia  results. 

In  the  way  of  treatment  hot  fomentations  are  used,  and  atropine 
when  there  is  iritis,  and  constitutional  remedies.  The  prognosis,  how- 
ever, is  unfavorable. 

Gumma  of  the  sclera  is  seen  occasionally,  either  arising  primarily  in 
the  sclera  or»extending  there  from  gumma  of  the  ciliary  body. 

The  deep  non-ulcerous  inflammations  of  the  cornea  which  are  due 
to  syphilis  are  of  the  following  varieties  :  typical  parenchymatous  or 
interstitial  keratitis,  parenchymatous  punctate  keratitis,  sclerosing  kera- 
titis, and  gummata  in  the  cornea. 

Typical  parenchymatous  keratitis  is  sometimes  seen  early  in  the 
course  of  acquired  syphilis,  is  sometimes  due  to  uveal  tuberculosis,  and 
in  a  few  cases  no  cause  can  be  discovered  ;  in  general,  however,  it  is,  as 
Hutchinson  first  pointed  out,  a  characteristic  symptom  of  inherited 
syphilis.  It  is  met  with  most  frequently  between  the  ages  of  six  and 
twenty,  occasionally  between  twenty  and  thirty,  and  rarely  after  thirty. 

At  the  beginning  of  the  affection  a  few  punctate,  linear,  or  patchy 
opacities  of  pale  bluish-gray  color  are  seen  scattered  through  the  deeper 
layers  of  the  cornea,  unaccompanied  by  marked  signs  of  inflammation. 
These  small  opacities  soon  multiply  and  coalesce  until  the  greater  portion 
of  the  cornea  is  diffusely  hazy  and  of  a  milky  hue,  or  comes  to  have 
the  appearance  of  ground  glass.     Sooner  or  later  signs  of  a  mild  iritis 


SCLERA   AND   CORNEA.  587 

appear,  and  there  is  circumcorneal  injection  with  photophobia  and 
lachrymation,  which  increase  later  when  the  cornea  becomes  vascular. 

After  some  weeks  or  months  new-formed  vessels  start  from  the 
margin  of  the  cornea  and  run  toward  its  centre.  These  vessels,  for  the 
most  part,  lie  deep  in  the  corneal  substance,  and  run  parallel  to  one 
another,  without  branching,  and  they  may  be  present  in  such  numbers 
as  to  form  a  distinct  red  spot.  The  bright  scarlet  color  of  the  vessels, 
however,  is  paled  by  the  overlying  corneal  opacities,  and  the  result  is  the 
"  salmon  patch  "  of  Hutchinson. 

With  the  vascularization,  the  corneal  opacity  gradually  clears  up 
from  the  periphery,  remaining  longest  in  the  centre  of  the  cornea,  where 
the  absorption  is  rarely  so  complete  that  characteristic  opacities  do  not 
permanently  remain.  The  course  of  the  disease  is  essentially  chronic, 
as  it  lasts  from  six  to  eighteen  months,  and  is  prone  to  relapse.  The 
affection  is  almost  always  bilateral,  the  second  eye  being  attacked  a  few 
weeks  or  months  after  the  first. 

At  the  outset,  so  varying  is  the  clinical  picture,  the  diagnosis  may  be 
quite  difficult,  but  corroborative  evidence  can  be  obtained  merely  by  ob- 
serving the  head,  which  usually  presents  stigmata  of  hereditary  syphilis  : 
the  frontal  eminences  are  prominent,  the  bridge  of  the  nose  sunken,  the 
skin  pasty,  with  linear  scars  about  the  nostrils  and  the  angles  of  the 
mouth,  and  the  secondary  central  incisor  teeth  notched.  Furthermore, 
the  lymphatic  glands  generally  are  slightly  enlarged  and  hard,  and 
nodules  are  often  to  be  found  on  the  tibias. 

Pathologically,  parenchymatous  keratitis  is  now  regarded  as  an  affec- 
tion accessory  to,  and  in  a  way  dependent  upon,  disease  of  the  uveal  tract. 

The  local  treatment  is  directed  particularly  against  the  iritis,  the 
pupil  being  kept  fully  dilated  with  atropine  to  prevent  the  formation 
of  posterior  synechia?.  Warm  fomentations  are  employed,  and  the  eyes 
are  protected  from  the  light.  Antisyphilitic  treatment  does  not  per- 
ceptibly shorten  the  course  of  the  disease,  and,  while  it  is  customary  to 
employ  it,  it  must  be  supplemented  with  tonics  and  hygienic  regulations. 
After  the  absorption  of  the  opacities  is  well  under  way  it  may  be  has- 
tened by  the  sparing  use  of  irritants,  such  as  1  per  cent,  yellow  oxide 
of  mercury  ointment,  or  wine  of  opium  and  water  in  equal  parts. 

Parenchymatous  punctate  keratitis,  which  was  first  described  by 
Mauthner,  is  a  rare  affection  occurring  in  the  early  stages  of  acquired 
syphilis.  It  is  characterized  by  the  presence  of  a  number  of  discrete 
grayish  dots,  of  pin-head  size,  lying  in  the  deep  layers  of  the  cornea,  and 
it  is  not  accompanied  by  diffuse  haziness  or  vascularity  of  the  cornea  or 
by  any  signs  of  iridocyclitis.  It  is  to  be  distinguished  clinically  from 
supa*ficial  punctate  keratitis,  a  commoner  affection,  in  which  small 
nodules  lie   near  the  surface   of  the  cornea,  elevating  its  epithelium. 


588  SYPHILITIC  AFFECTIONS  OF  THE  EYE. 

And  it  is  not  to  be  confounded,  because  of  its  name,  with  the  condition 
formerly  called  punctate  keratitis,  in  which  products  of  uveal  inflam- 
mation are  deposited  on  the  posterior  surface  of  the  cornea  in  its  lower 
half. 

A  rare  variety  of  syphilitic  punctate  keratitis,  somewhat  allied  to 
typical  parenchymatous  keratitis,  presents  the  gray  punctate  opacities, 
but  they  are  accompanied  by  diffuse  opacity  of  the  cornea  and  by  iritis. 

Sclerosing  keratitis  sometimes  occurs  late  in  the  course  of  syphilis, 
although  it  is  more  frequently  seen  in  persons  with  rheumatism  or  gout. 
It  is  to  be  regarded  as  a  component  of  the  complex  affection  generically 
known  as  uveitis  anterior.  This  is  a  chronic,  relapsing,  alternating 
inflammation  of  the  various  parts  that  are  nourished  chiefly  by  the 
anterior  ciliary  arteries,  viz.,  the  ciliary  body  and  iris,  the  sclera,  and 
the  cornea.  Following  a  chronic  infiltration  of  the  ciliary  body  and 
sclera,  a  dense  yellowish-gray  opacity  appears  in  the  contiguous  sector 
of  the  cornea,  and,  later,  it  becomes  white  or  bluish-white,  resembling 
a  continuation  of  the  sclera.  This  opacity,  unlike  that  of  ordinary 
parenchymatous  keratitis,  shows  little  tendency  to  undergo  absorption. 

True  gummata  may  appear  in  the  cornea  in  the  late  stages  of 
syphilis. 

IRIS  AND  CILIARY  BODY. 

Iritis  may  be  due  to  syphilis,  rheumatism,  gout,  diabetes,  or  gonor- 
rheal rheumatism.  More  than  one-half  of  the  non-traumatic  cases  of 
iritis,  however,  are  due  to  acquired  syphilis,  and  hence  iritis  is  almost 
as  characteristic  a  symptom  of  acquired  syphilis  as  parenchymatous 
keratitis  is  of  hereditary  syphilis.  In  hereditary  syphilis  uncompli- 
cated iritis  is  not  common. 

The  process  in  iritis  consists  in  hypersemia  and  infiltration  of  the 
iris  and  ciliary  body  and  in  exudation  into  the  aqueous  and  vitreous 
humors.  The  character  of  the  exudation  determines  the  clinical  variety, 
iritis  being  classified  as  plastic,  serous,  spongy,  and  purulent. 

Plastic  iritis  when  due  to  acquired  syphilis  is  seen  most  frequently 
within  the  first  year  of  the  disease,  and  it  often  appears  with  the  first 
eruption  on  the  skin.  Both  eyes  may  be  affected,  either  together  or 
successively.  At  the  outset  the  patient  notices  an  injection  of  the 
eyeball,  with  photophobia,  lachrymation,  pain  not  only  in  the  eye  but 
also  radiating  from  it  to  the  forehead  and  temple,  and  blurring  of 
vision.  When  examined  there  is  seen  a  dark  purplish-red  zone  of 
circumcorneal  injection,  and  the  iris  appears  dull  and  lustreless,  and 
so  swollen  that  the  surface-markings  are  obscured.  The  pupil  is 
small,  irregular  in  shape,  and  responds  to  light  but  slightly,  if  at  all. 
The  aqueous  and  vitreous  humors  are  cloudy,  and  deposits  of  exuda- 


IRIS  AND   CILIARY  BODY.  589 

tion  lie  on  the  posterior  surface  of  the  cornea  and  the  anterior  surface 
of  the  lens.  When  the  pupil  is  dilated  with  atropine  the  margin  of 
the  iris  is  found  to  be  bound  down  to  the  lens  here  and  there  by 
posterior  synechia?,  so  that  the  outline  of  the  pupil  is  notched  and 
irregular.  With  the  continued  use  of  atropine  the  adhesions  are  often 
broken  up. 

Iritis,  in  acute  cases,  runs  its  course  in  from  four  to  eight  weeks. 
The  swelling  and  discoloration  of  the  iris  then  disappear  and  the  exuda- 
tions are  absorbed.  Relapses  are  frequent,  however,  and  recurrence  is 
not  uncommon.  It  frequently  happens  that  some  posterior  synechias 
persist,  or  pigmented  spots  where  synechias  have  existed  remain  on 
the  anterior  surface  of  the  lens,  indicating  ever  afterward  that  there 
has  been  iritis. 

If  the  pupil  is  not  kept  fully  dilated  with  atropine,  organized  adhe- 
sions form,  binding  the  whole  pupillary  margin  of  the  iris  down  to  the 
lens,  and  a  dense  membrane  may  develop  in  the  pupil.  The  aqueous 
humor  is  then  unable  to  pass  from  the  posterior  to  the  anterior  chamber 
to  gain  its  channels  of  outlet,  and  a  glaucomatous  condition  is  set  up 
which  requires  iridectomy. 

In  the  plastic  iritis  of  the  early  stage  of  syphilis  one  or  more  nodules 
may  form  at  the  pupillary  margin  or  occasionally  at  the  ciliary  margin 
of  the  iris.  These  are  granulation  tumors  corresponding  to  papules  or 
condylomata  on  the  skin,  and  are  characteristic  of  syphilis.  They  may 
undergo  necrosis  and  disappear  without  leaving  a  scar,  and  the  yellowish 
debris  sinking  down  to  the  bottom  of  the  anterior  chamber  may  give 
rise  to  the  clinical  picture  of  hypopyon,  but  true  purulent  iritis  with 
hypopyon  is  rarely  due  to  syphilis. 

In  the  later  stages  of  syphilis  true  gummata  sometimes  appear  in  the 
iris  and  lead  to  considerable  destruction  of  tissue,  or  gummata  form  in 
the  ciliary  body  and  sometimes  lead  to  perforation  of  the  ball. 

The  patient  with  plastic  iritis  is  kept  in  bed  in  a  darkened  room ; 
leeches  may  be  applied  to  the  temple ;  1  per  cent,  atropine  solution  is 
instilled  often  enough  to  keep  the  pupil  fully  dilated ;  hot  fomentations 
are  used  frequently;  constitutional  treatment  is  instituted;  and  one  of 
the  coal-tar  analgesics  is  at  times  required  to  relieve  the  nocturnal  pain. 

Serous  iritis  is  less  frequent  than  plastic  and  is  less  frequently  due 
to  syphilis  than  to  rheumatism.  Pathologically  it  is  rather  a  cyclitis 
than  an  iritis.  The  subjective  symptoms  are  like  those  of  plastic  iritis 
and  the  same  circumcorneal  injection  is  present;  the  pupil,  however, 
may  be  of  natural  size  or  even  somewhat  dilated,  the  swelling  of  the 
iris  may  not  be  marked,  and  adhesions  to  the  lens,  if  they  exist,  are 
usually  so  slight  as  to  be  easily  broken  up.  The  characteristic  symptom 
is  the  presence  on  the  posterior  surface  of  the  cornea,  in  its  lower  half, 


590  SYPHILITIC  AFFECTIONS  OF  THE  EYE. 

of  fine  punctate  deposits,  usually  yellowish  in  color,  but  sometimes  pig- 
mented, which  are  often  arranged  in  the  form  of  a  triangle  with  its 
apex  up.  The  affection  at  times  may  be  a  cyclitis  purely;  the  iris  then 
is  of  normal  appearance,  but  the  eyeball,  besides  beiDg  painful,  is  very 
sensitive  to  pressure  in  the  ciliary  region. 

In  serous  iritis,  as  in  all  affections  in  which  the  ciliary  body  is 
involved,  disturbances  of  intra-ocular  tension  are  frequent ;  and,  while 
atropine  is  indicated,  as  a  rule,  the  tension  must  be  watched  and  any 
increase  appropriately  treated. 

Spongy  iritis  is  rare,  and  is  not  often  due  to  syphilis.  In  this  variety 
of  iritis  the  fibrin-forming  elements  of  the  blood  are  poured  out  and  a 
yellowish-gray  coagulum,  resembling  a  dislocated  crystalline  lens,  fills 
the  entire  anterior  chamber.  This  coagulum  gradually  undergoes  ab- 
sorption and,  as  it  becomes  smaller,  sinks  down  to  the  bottom  of  the 
chamber. 

CHOROID  AND  RETINA. 

The  choroid,  with  its  rich  vascular  supply,  nourishes  the  non-vascular 
outer  layers  of  the  retina,  and  in  inflammations  of  the  choroid  these 
outer  layers  of  the  retina  suffer  also,  so  that  the  ordinary  inflammation 
is  properly  a  chorioretinitis.  The  retinal  vessels  supply  the  inner 
layers  of  the  retina,  and  an  inflammation  arising  in  the  retina  usually 
remains  limited  to  these  layers,  and  is  properly  a  retinitis  of  the  inner 
layers. 

These  affections  of  the  background  of  the  eye  do  not  cause  pain  or 
external  evidences  of  inflammation,  and  the  chief  subjective  symptom 
is  a  disturbance  of  vision,  which  may  be  so  slight  as  to  pass  unobserved 
by  the  patient.  When  the  inflammatory  foci  are  in  the  macular  region, 
however,  gaps  will  be  noticed  in  the  field  of  vision  and  objects  observed 
will  often  appear  distorted  and  altered  in  size. 

The  affections  of  the  choroid  that  may  be  due  to  syphilis,  occurring 
as  late  symptoms,  are,  in  the  order  of  their  frequency,  chronic  dissem- 
inate choroiditis,  acute  exudative  choroiditis,  and  choroiditis  as  a  part  of 
a  general  uveitis.  These  inflammations  in  the  majority  of  cases  are  not 
syphilitic,  and  a  constitutional  cause  cannot  always  be  discovered.  Dis- 
seminate choroiditis  is  a  very  chronic  affection,  characterized  by  the 
presence  of  yellowish  or  reddish  foci  of  infiltration,  usually  as  large 
as  the  optic  disk  or  larger,  scattered  through  the  fundus.  The  choroid 
undergoes  atrophy  in  the  affected  areas  and  finally  the  sclera  shows 
through  as  a  white  patch  bordered  by  a  zone  of  pigment. 

The  vitreous  may  be  slightly  cloudy,  but,  if  the  foci  are  peripheric 
and  do  not  affect  central  vision,  the  disease  may  pass  unnoticed  for 
years. 


CHOROID  AND  RETINA.  591 

In  hereditary  syphilis  it  is  usual  to  find  a  disseminate  choroiditis 
localized  in  the  anterior  segment  of  the  choroid  near  the  ora  serrata, 
and  with  this  there  may  be  pallor  of  the  optic  disk  and  constriction 
of  the  retinal  arteries,  central  vision,  however,  being  normal. 

Areolar  choroiditis  is  a  form  of  chronic  choroiditis  characterized  by 
the  presence  of  black  patches  near  the  posterior  pole  of  the  eye,  which 
later  often  become  lighter  in  their  centres. 

In  cases  of  extensive  choroiditis  there  may  be  a  general  absorption 
of  the  pigment  from  the  pigment-epithelium  and  a  deposition  of  it  in 
branched  figures  in  the  inner  layers  of  the  retina.  This  condition  is 
sometimes  confounded  with  retinitis  pigmentosa,  but  the  latter  affection 
does  not  exhibit  visible  changes  in  the  choroid,  and  it  is  never  due  to 
syphilis. 

Acute  exudative  choroiditis  begins  as  an  elevated  yellowish  patch 
of  infiltration,  usually  oval  in  form,  with  its  outlines  blurred  from  the 
haziness  of  the  overlying  retina.  There  may  be  hemorrhages  in  the 
retina  about  the  patch,  and  the  retinal  vessels  near  it  may  be  dilated. 
Furthermore,  the  optic  disk  may  be  swollen,  particularly  on  the  side 
toward  the  patch,  and  present  the  picture  of  optic  neuritis.  Very  soon 
membranous  opacities  appear  in  the  vitreous  over  the  patch,  and  a  dif- 
fuse haziness  of  the  entire  vitreous  blurs  the  sight.  The  fundus  may 
then  be  so  obscured  that  the  diagnosis  is  difficult,  but  a  small  abso- 
lute scotoma  can  usually  be  made  out  in  the  visual  field  and  the  inflam- 
matory patch  can  thus  be  located. 

In  a  month  or  two  the  opacities  of  the  vitreous  clear  up,  the  cho- 
roidal exudation  is  absorbed,  the  choroid  and  outer  layers  of  the  retina 
atrophy,  and  the  sclera  then  shows  through  as  a  white  patch  crossed  by 
a  few  remaining  choroidal  vessels  and  surrounded  by  a  zone  of  pig- 
ment. 

A  central  chorioretinitis  of  rare  occurrence  is  that  form  in  which 
the  exudation  into  the  tissue  is  not  absorbed,  but  becomes  organized, 
and  there  remains  instead  of  the  usual  atrophic  spot  a  thick  elevated 
patch  of  new  connective  tissue. 

Diffuse  choroiditis  appears  at  times  as  a  component  of  a  general 
uveitis.  The  nutrition  of  the  lens  and  vitreous  is  interfered  with,  there 
are  marked  disturbances  of  intra-ocular  tension,  and  the  final  outcome 
of  the  process  may  be  atrophy  of  the  eyeball. 

In  the  treatment  of  choroiditis,  rest  and  the  protection  cf  the  eyes 
from  bright  light  are  to  be  enjoined,  and  the.  constitutional  remedies 
employed  will  be  either  alterative  or  tonic,  according  to  the  patient's 
physical  state  and  the  acuteness  of  the  local  affection. 

Syphilitic  retinitis  may  appear  either  as  an  early  or  as  a  late  mani- 
festation.    It   is   rare   as  compared  with   retinitis   due  to  albuminuria, 


592  SYPHILITIC  AFFECTIONS  OF  THE  EYE. 

diabetes,  and  lesions  of  the  circulatory  system.  In  the  severe  cases 
the  entire  retina  becomes  diffusely  hazy,  but  more  markedly  so  near  the 
optic  disk  where  the  nerve-fibre  layer  is  thickest.  The  disk  itself  is 
swollen  and  the  retinal  veins  are  large  and  tortuous.  Occasionally 
there  are  hemorrhages  or  yellowish  exudations  along  the  larger  vessels. 
If  there  is  a  complicating  choroiditis  there  may  be  a  very  dense  diffuse 
cloudiness  of  the  vitreous,  obscuring  the  fundus.  In  milder  cases 
the  retinal  vessels  are  not  much  changed  in  size,  and  portions  of  the 
retina  appear  merely  veiled  by  a  faint  bluish-gray  haze,  which  may  be 
so  tenuous  as  to  escape  detection.  The  extent  of  the  affected  areas  can, 
however,  be  mapped  out  in  the  visual  field  by  delicate  tests,  such  as 
using  colored  test-objects  or  pale  gray  test-objects  on  a  white  ground. 

The  affection  runs  no  regular  course,  but  undergoes  rapid  variations 
and  is  very  chronic.  It  may  pass  off,  however,  leaving  the  vision  little 
impaired.     Energetic  constitutional  treatment  is  demanded. 

A  relapsing  central  retinitis  of  syphilitic  origin  has  been  described 
by  Graefe,  in  which  a  slight  cloudiness  appears  at  the  macula  lutea, 
causing  a  relative  central  scotoma,  and  then  disappears  to  recur  again 
and  again,  until  eventually  central  vision  is  permanently  impaired. 

OPTIC   NERVE. 

The  syphilitic  affections  of  the  optic  nerve  are  usually  quite  late 
manifestations  of  the  disease.  They  include  both  inflammations  and 
degenerations,  and  they  differ  in  general  from  similar  affections  due  to 
other  causes  in  their  rapid  variations  and  in  their  tendency  to  improve 
under  treatment. 

A  papillitis  involving  only  the  bulbar  end  of  the  nerve  always 
accompanies  the  severer  forms  of  syphilitic  retinitis.  There  is  then 
moderate  swelling  of  the  optic  disk,  with  dilatation  of  the  veins  and 
narrowing  of  the  arteries ;  but  with  the  subsidence  of  the  retinitis  the 
disk  may  regain  its  normal  appearance,  and  vision  may  become  per- 
fect again. 

Retrobulbar  neuritis  with  central  scotoma  is  rare  in  syphilis. 

Optic  neuritis  of  low  degree  without  much  involvement  of  the  adja- 
cent retina  is  a  very  frequent  accompaniment  of  syphilitic  inflammatory 
deposits  at  the  base  of  the  brain.  The  dura  particularly  is  disposed  to 
gummous  thickenings,  and  if  this  new-formed  material  involves  the 
optic  nerves,  chiasm,  or  tracts  there  is  set  up  a  slight  bilateral  optic 
neuritis.  This  neuritis  is  very  chronic,  but  it  may  not  greatly  impair 
vision,  and  it  can  be  held  in  check  by  constitutional  treatment. 

An  excessive  bilateral  papillitis,  or  choked  disk,  which  after  a  time 
may  rapidly  destroy  vision  and  later  present  the  picture  of  post-neuritic 
atrophy  of  the  nerve,  comes  on  in  many  cases  of  intracranial  gumma. 


MOTOR  XERVES.  593 

It  does  not  differ  from  the  choked  disk  of  other  brain  tumors,  but  it 
requires  very  energetic  constitutional  treatment,  for  the  patient  may 
recover  from  the  other  effects  of  the  gumma  and  remain  completely  and 
permanently  blind  from  the  papillitis  which  the  gumma  has  set  up. 

Unilateral  choked  disk  may  be  brought  about  by  gumma  of  the  orbit, 
which  at  the  same  time  causes  exophthalmos  and  often  paralysis  of  the 
ocular  muscles  from  pressure  upon  the  orbital  nerves. 

In  syphilitic  simple  or  non-inflammatory  optic-nerve  atrophy  the 
optic  disk  grows  pale,  but  it  always  remains  sharply  outlined  and  the 
retinal  vessels  for  a  time  preserve  their  normal  size.  Late  in  the  course 
of  the  affection  the  optic  disk  grows  perfectly  white  and  the  retinal 
vessels  become  narrow.  This  atrophy  is  a  degeneration  of  the  optic 
fibres  due  to  compression  somewhere  in  their  course,  either  from  neo- 
plastic tissues  without,  or  from  inflammatory  changes  within,  the  nerve 
or  tract,  but  so  far  back  that  they  do  not  reveal  themselves  by  signs  of 
inflammation  in  the  optic  disk. 

In  atrophy  due  to  softening  of  the  basal  optic  centres  on  one  side  or 
to  pressure  on  one  optic  tract  there  is  homonymous  hemianopsia. 
Pressure  on  the  middle  portion  of  the  chiasm  produces  bitemporal 
hemianopsia.  But,  as  a  rule,  there  is  diffuse  pressure  upon  the  chiasm 
and  the  adjacent  portions  of  the  nerves  and  tracts,  producing  a  concen- 
tric contraction  of  the  field  of  vision  in  each  eye. 

Constitutional  treatment  will  sometimes  check  the  failure  of  vision 
or  even  bring  about  improvement.  In  this  respect  syphilitic  optic- 
nerve  atrophy  differs  from  tabic  optic-nerve  atrophy ;  for  however  im- 
portant the  role  of  syphilis  may  be  in  the  production  of  tabes,  tabic  proc- 
esses are  rather  hastened  than  retarded  by  antisyphilitic  treatment,  and 
tabic  optic-nerve  atrophy,  in  spite  of  treatment,  steadily  progresses. 

MOTOR  NERVES. 

Paralyses  of  the  ocular  muscles  are  perhaps,  in  the  majority  of  cases, 
due  to  syphilis.  These  paralyses  may  be  brought  about  in  a  variety  of 
ways.  Thus,  the  nerve-trunk  may  suffer  compression  from  deep  orbital 
periostitis,  gumma  at  the  base  of  the  brain,  basilar  meningitis,  and  the 
like.  The  sixth  nerve  is  then  frequently  affected,  since  it  has  the 
longest  course  on  the  floor  of  the  skull  and  is  the  most  exposed  nerve 
in  the  sphenoidal  fissure.  The  third,  fourth,  and  fifth  nerves  also  may 
be  affected,  and  optic  neuritis  may  develop. 

Again,  the  nuclei  of  the  nerves  may  be  affected  by  changes  in  the 
vessels  supplying  them,  or  by  chronic  polio-encephalitis  superior.  In 
this  case  the  nuclei  for  single  muscles  may  be  affected,  giving  rise  to 
isolated  paralysis,  such,  for  example,  as  that  of  the  superior  oblique,  or 
of  the  ciliary  muscle  and  sphincter  of  the  pupil  on  one  side. 

38 


594  SYPHILITIC  AFFECTIONS   OF  THE  EYE. 

Or,  again,  there  may  be  progressive  involvement  of  the  nuclei, 
causing  paralysis  of  one  muscle  after  another  in  both  eyes,  together  with 
anosmia,  facial  paralysis,  and,  later,  simple  atrophy  of  the  optic  nerves. 

Cortical  and  subcortical  lesions  also  give  rise  to  ocular-muscle 
paralysis,  but  in  this  case  usually  a  number  of  muscles  will  be  affected 
simultaneously,  and  other  motor  disturbances  will  be  present.  An  iso- 
lated unilateral  ptosis,  however,  may  occur  with  a  cortical  lesion  of  the 
opposite  side. 

An  increasing  pressure  on  the  third-nerve  trunk  from  syphilitic 
deposits  will  cause  paralysis  of  one  after  another  of  the  muscles  sup- 
plied by  this  nerve,  the  levator  of  the  upper  lid  often  being  the  first 
to  suffer.  Unilateral  ptosis,  therefore,  when  not  congenital,  usually 
indicates  syphilis. 

The  syphilitic  paralyses  may  pass  off  in  the  course  of  weeks  or 
months,  but  they  are  often  resistant  to  treatment,  and  are  at  times 
permanent.  Tabic  ocular-muscle  paralyses,  with  which  these  are  not 
to  be  confounded,  usually  are  recovered  from  quickly,  but  are  prone 
to  recur. 

Antisyphilitic  treatment  is  to  be  pushed,  and,  if  the  diplopia  is 
annoying,  a  ground  glass  may  be  worn  before  one  eye,  shutting  off  one 
of  the  double  images.  If,  after  months  of  treatment,  the  function  of  a 
paralyzed  muscle  is  regained  in  part,  but  not  completely,  the  muscle 
may  be  advanced  with  tenotomy  of  its  antagonist,  or  its  synergist  in  the 
other  eye  may  be  tenotomized. 


CHAPTER    XXXVI. 

SYPHILITIC   AFFECTIONS  OF  THE    EAR 

Syphilitic  affections  of  the  ear  are  rare  as  compared  with  syphil- 
itic affections  of  the  eye,  and  few  of  them  are  characteristic. 

EXTERNAL  EAR. 

Cutaneous  manifestations  of  syphilis  occurring  on  or  about  the  ear  do 
not  differ  particularly  from  those  occurring  elsewhere  in  the  body. 

The  early  secondary  rashes  oftentimes  involve  the  mastoid  region, 
the  auricle,  the  meatus,  and  even  the  drum-membrane.  Occasionally  a 
condyloma  is  seen  on  the  auricle  or  in  the  meatus,  appearing  as  a  dull- 
red,  warty  excrescence,  whose  surface  is  either  moist  or  dry  and  scaly. 
When  the  condyloma  is  situated  in  the  meatus  it  will  block  the  passage 
more  or  less  completely  and  give  rise  to  a  profuse  purulent  discharge, 
and  it  may  even  bring  about  a  general,  diffuse  inflammation  of  the 
meatus. 

Gumma  of  the  auricle  leads  at  times  to  deep  ulceration,  with  destruc- 
tion of  cartilage  and  resulting  deformity,  and  superficial  eruptions  may 
give  rise  to  shallow  ulcers. 

Periostitis  of  the  meatus  occurs  at  times  in  syphilis,  and  exostoses 
have  been  thought  by  some  to  arise  from  this  cause ;  but  a  large  per- 
centage of  those  suffering  from  exostosis  of  the  meatus  do  not  have 
syphilis,  and  it  is  not  certain  that  syphilis  ever  causes  exostoses  here. 

Ulcerations  and  moist  areas  are  to  be  dusted  with  calomel,  painted 
with  nitrate  of  silver  solution,  or  covered  with  an  emollient  ointment ; 
and  granulations  are  to  be  cauterized  or  excised. 

MIDDLE  EAR. 

The  ordinary  inflammations  of  the  middle  ear,  both  non-suppurative 
and  purulent,  genetically  stand  in  close  relationship  with  affections  of 
the  rhinopharynx,  and  are  readily  brought  about  by  syphilitic  affec- 
tions of  the  nose  and  throat.  Besides  these  secondary  inflammations, 
primary  periosteal  inflammation  of  the  middle  ear  may  also  be  caused 
by  syphilis. 

There  is  nothing  characteristic  about  the  chronic  non-suppurative 
inflammations  of  the  middle  ear  in  syphilis,  except  that  thev  prove 
refractory  to  simple  treatment ;  and  the  importance  of  the  syphilitic 
factor  in  their  production  is  only  to  be  made  out  in  an  individual  case 

595 


596  SYPHILITIC  AFFECTIONS  OF  THE  EAR. 

by  a  trial  of  antisyphilitic  treatment.  In  children  with  hereditary- 
syphilis  the  rhinitis,  commonly  called  "  snuffles,"  is  a  frequent  cause  of 
middle-ear  disease. 

Suppurative  middle-ear  inflammation  may  lead  to  mastoiditis,  sinus- 
thrombosis,  meningitis,  and  brain  abscess ;  and,  in  all  these  complica- 
tions, as  well  as  in  the  middle- ear  affection  itself,  the  existence  of 
syphilis  renders  the  prognosis  more  grave. 

Chancre  at  the  orifice  of  the  Eustachian  tube,  which  has  been  caused 
in  many  instances  by  the  use  of  an  infected  catheter,  or  ulceration  in 
this  region  may  block  the  tube ;  while  later,  the  resulting  scars  may 
render  it  unduly  patent.  The  tubal  cartilage  may  undergo  fatty 
degeneration.  And  frequently  the  diffuse  rhinopharyngitis  of  the  early 
stages  of  syphilis  will  give  rise  to  an  obstinate  chronic  catarrhal  otitis 
media  that  rapidly  impairs  the  hearing. 

The  local  treatment  of  non-suppurative  inflammation  of  the  middle 
ear  consists  in  giving  attention  to  the  nose  and  throat,  and  in  inflating 
the  Eustachian  tube  ;  of  suppurative  inflammations,  in  carefully  cleansing 
the  ear,  making  antiseptic,  astringent,  or  caustic  applications,  and  in 
removing  granulations  and  carious  bone.  In  all,  antisyphilitic  treatment 
is  to  be  employed. 

INTERNAL  EAR. 

Affections  of  the  internal  ear  are  seen  occasionally  in  acquired 
syphilis  and  very  frequently  in  the  hereditary  form.  Thus  Hutchin- 
son's triad  of  characteristic  symptoms  of  hereditary  syphilis  comprised 
deafness,  parenchymatous  keratitis,  and  notched  teeth. 

Affections  of  the  internal  ear  either  develop  in  the  course  of  middle- 
ear  disease  or  they  originate  primarily  in  the  internal  ear,  beginning 
abruptly  with  well-marked  symptoms.  In  the  latter  case  the  patient 
notices  tinnitus  of  high  pitch,  vertigo,  and  defective  hearing.  There 
may  also  be  nausea,  headache,  and  delirium.  Hearing  by  bone  con- 
duction is  diminished,  and  the  perception  of  high  tones  is  lost  or  inter- 
fered with.  The  subjective  symptoms  after  a  time  pass  off,  and  the 
hearing  that  remains  may  be  preserved  ;  but  usually  it  gradually  fails. 
In  patients  with  hereditary  syphilis  who  become  deaf  from  labyrinthine 
disease  the  drum-membranes  later  usually  show  evidences  of  a  simul- 
taneous affection  of  the  middle  ear. 

The  pathology  of  syphilitic  labyrinthine  disease  consists,  first,  in 
infiltration  and  swelling  of  the  membranous  tissues  of  the  labyrinth, 
interfering  with  the  function  of  the  nervous  apparatus  ;  and,  later,  in 
actual  hypertrophy  of  the  connective  tissues  leading  to  cicatricial  shrink- 
ing, with  consecutive  atrophy  of  the  nervous  elements. 

The  prognosis  as  regards  the  recovery  of  hearing  that  has  once  been 


INTERNAL  EAR.  597 

lost  is  bad.  Hence  in  patients  known  to  suffer  from  hereditary  syphilis 
ear  symptoms  should  be  attentively  looked  for,  and  when  found  treated 
without  delay. 

Treatment  in  the  acute  stage  consists  in  the  application  of  leeches 
below  the  mastoid,  the  employment  of  general  antiphlogistic  measures, 
and  the  use  of  pilocarpine.  Constitutional  treatment  is  indicated  in  all 
stages. 


CHAPTER   XXXVII. 

,     .  TERTIARY  SYPHILIS. 

When  syphilis  does  not  become  extinct  in  the  secondary  stage  it 
passes  into  a  chronic  condition,  called  tertiary  syphilis. 

The  evolution  of  tertiary  syphilis,  as  a  rule,  is  slow,  uncertain,  in- 
sidious, and  unattended  by  local  or  general  prodromata.  While  in 
secondary  syphilis  the  infection  very  often  runs  an  orderly  course,  and 
a  general  estimate  may  be  formed  as  to  what  morbid  conditions  and 
lesions  may  be  expected  in  tertiary  syphilis,  as  a  rule,  there  are  no 
special  criteria  to  govern  us  in  our  prognosis,  since  all  is  occult  and 
without  order  or  system.  The  tertiary  stage  has  very  aptly  been  called 
the  terra  incognita  of  syphilis. 

Tertiary  syphilis  presents  in  its  evolution  and  course  many  striking 
differences  from  the  secondary  form.  Tertiary  lesions,  as  a  rule,  are  of 
deep  development,  of  compact  structure,  and  of  slow  and  aphlegmasic 
nature.  They  are  usually  less  numerous  and  more  isolated  than  secondary 
lesions,  less  certain  as  to  their  seat,  less  regular  in  their  course,  and 
much  more  deeply  seated  and  destructive  in  their  tendency. 

Tertiary  lesions  attack  the  subdermal  and  submucous  connective 
tissues,  and  produce  in  them  more  or  less  extensive  and  dense  infiltra- 
tions, most  of  which  show  a  tendency  to  degeneration.  While  in 
secondary  syphilis  the  more  superficial  strata  of  the  skin  and  mucous 
membranes  are  involved,  in  the  tertiary  stage  the  whole  thickness  of 
these  structures  is  attacked.  In  secondary  syphilis  the  skin  lesions  are 
more  generalized,  more  numerous,  and  are  symmetrically  placed.  In 
the  tertiary  stage  their  number  is  restricted  ;  they  are  usually  irregularly 
distributed,  and  very  often  their  arrangement  is  unsymmetrical.  The 
old  eruptions  are  localized  to  one  region,  and  they  may  perhaps  exist  in 
several. 

In  secondary  syphilis  we  not  infrequently  see  a  tendency  in  the 
lesions  to  undergo  involution  and  resolution  ;  in  tertiary  syphilis  no 
tendency  to  spontaneous  retrogression  of  its  lesions  is,  as  a  rule,  seen. 
While  in  the  majority  of  cases  of  secondary  syphilis  the  viscera  are 
spared  or  are  the  seat  only  of  irritative  or  hypersemic  processes,  in 
tertiary  syphilis  they  are  attacked  more  or  less  deeply  by  a  chronic 
progressive  infiltrative  process  which  produces  nodules,  plaques,  and 
tumors  called  gummy  tumors,  or  syphilomata.     Thus  in  its  far-reaching 

598 


TERTIARY  SYPHILIS.  599 

and  pathological  action  tertiary  syphilis  involves  not  only  the  super- 
ficies of  the  body,  but  also  its  internal  parts — the  viscera,  the  bones 
and  their  adnexa,  the  muscles,  the  bloodvessels,  and  the  nervous  system. 

The  pathological  processes  in  tertiary  syphilis  are,  in  the  main, 
similar  to,  but  more  fully  developed,  intense,  and  exuberant  than,  those 
of  the  secondary  stage.  They  include,  in  brief,  perivascular  cell- 
changes,  round-cell  infiltration  (gummatous  infiltration  and  nodulation), 
and  irritative  processes  which  result  in  the  development  of  fibrous  or 
connective  tissues  (in  bones,  joints,  muscles,  tendons,  synovial  sheaths, 
and  the  skin  and  mucous  membranes),  and  last,  but  not  least,  the  ex- 
cessive development  of  connective-tissue  neuroglia  in  the  nervous  struct- 
ures of  the  cerebrospinal  axis.  These  processes  may  eventuate  in  the 
degenerative  conditions  already  mentioned. 

It  is  absolutely  impossible  to  write  a  clear  and  thoroughly  systematic 
clinical  history  of  tertiary  syphilis.,  since  no  two  cases  are  alike,  and  the 
date  of  invasion,  the  extent,  depth,  course,  and  seat  of  the  morbid  process, 
and  the  organs  or  tisuess  attacked,  are  usually  different  in  each  instance. 
While,  therefore,  no  sharply  and  precisely  drawn  clinical  divisions  can 
be  presented  in  describing  tertiary  syphilis,  certain  generalizations  may 
be  made  which  will  tend  to  give  a  clear  idea  of  this  chaotic  and  dis- 
cordant stage  of  syphilitic  infection. 

Tertiary  syphilis  in  a  rather  small  proportion  of  cases  develops  more 
or  less  precociously.  In  some  cases  as  early  as  the  second,  third,  or 
fourth  month  following  infection,  when  the  roseolous  syphilides  or  the 
papular  syphilides  are  still  present,  the  condition  of  the  patient  changes 
for  the  worse.  The  skin  lesions  increase  in  size,  ulcerate,  and  sup- 
purate perhaps  very  profusely.  The  resulting  ulcers  increase  in  size 
and  depth,  and  may  present  sloughy,  even  gangrenous,  features.  Then 
these  lesions  show  a  tendency  to  spread  over  the  trunk,  the  extremities, 
the  face,  and  the  scalp.  With  these  ulcerations  cutaneous  gummata,  or 
more  superficial  but  thick  tubercles,  may  develop,  soften,  and  lead  to 
deep  ulcers.  The  patient  then  becomes  weak  and  cachectic.  In  a  small 
proportion  of  these  cases  such  nervous  affections  as  hemiplegia,  aphasia, 
meningeal  hyperemia,  epilepsy,  paralysis  of  the  motor  oculi  and  facial 
nerves,  and  degenerative  changes  in  the  optic  and  auditory  nerves,  may 
be  seen.  This  form  of  tertiary  syphilis  in  very  rare  instances  runs  an 
unusually  rapid  and  severe  (called  by  some  galloping  or  lightning-like) 
course,  and  soon  ends  in  death,  which  is  due  to  a  decidedly  febrile  state 
and  marasmus.  These  cases  sometimes  present  distinct  features  of 
septicaemia.  In  this  very  early  form  of  tertiary  syphilis  we  find 
multiple  large  and  severe  disseminated  and  generalized  ulcerations,  and 
an  adynamic  condition  of  the  system,  shown  by  the  malignancy  of  the 
infection  and  a  tendency  to  ulceration,  gangrene,  and  phagedena.     In 


600  TERTIARY  SYPHILIS. 

these  cases  the  syphilitic  infection  seems  to  luxuriate  exuberantly,  and 
its  action  is  very  rapid. 

Many  of  these  cases  of  precocious  tertiary  syphilis  are  cured  after  a 
hard  struggle  by  proper  treatment  and  suitable  hygiene. 

Tertiary  syphilis  may  be  rather  less  precocious  than  in  the  form  just 
described.  Toward  the  end  of  the  first  year  of  the  infection,  after  the 
evolution  of  secondary  manifestations,  some  patients  become  weak, 
anaemic,  and  lose  flesh.  One,  several,  or  many  ulcers,  which  may  arise 
de  novo  or  follow  in  the  wake  of  a  secondary  lesion,  may  appear  on 
the  scalp,  the  face,  or  the  extremities,  and  run  an  active  and  rapid 
course,  showing  great  rebelliousness  to  local  and  general  treatment  and 
careful  hygiene.  In  some  of  these  cases  there  are  concomitant  bone, 
joint,  pharyngonasal,  and  testicular  lesions.  The  patient  is  and  con- 
tinues to  be  a  sick  man  upon  whom  destructive  lesions  appear  at  short 
intervals.  In  most  of  these  cases,  after  a  very  severe  ordeal,  the  patient 
gradually  gains  health  and  strength,  and  may  be  in  the  end  cured.  In 
these  early  forms  of  tertiary  syphilis  it  is  not  uncommon  to  observe 
the  onset  of  pulmonary  tuberculosis,  which  usually  ends  fatally  in  a  few 
weeks  or  months. 

Nervous  affections  are  of  very  frequent  occurrence  in  precocious 
tertiary  syphilis,  the  brain  being  most  frequently  attacked.  The  spinal 
cord  is  much  less  frequently  affected. 

Death  from  brain  and  spinal-cord  lesions  is  to  be  feared  in  early 
tertiary  syphilis.  It  will  be  genei'ally  found  that  precocious  tertiary 
syphilis  is  much  more  rebellious  to  treatment  than  the  late  form.  In 
many  cases  treatment  seems  to  have  little  if  any  effect. 

The  results  of  the  experience  of  many  observers  go  to  show  that 
the  onset  of  tertiary  syphilis  occurs  in  the  third  or  fourth  year  of  the 
infection  in  the  majority  of  cases,  and  that  from  this  date  until  the 
tenth  or  twelfth  year  its  appearance  is  progressively  less  frequent. 
Tertiary  syphilis  may  in  exceptional  cases  develop  from  the  twelfth 
to  the  twentieth  year.  After  the  lapse  of  two  decades  tertiary  syphilis 
rarely  occurs. 

It  is  well  to  emphasize  the  point  that  the  possibility  of  error  in  the 
diagnosis  of  late  tertiary  lesions  is  great,  and  that  errors  are  common. 
It  is  always  a  good  plan  to  be  skeptical  about  alleged  cases  unless  they 
are  vouched  for  by  an  accurate  and  skilled  observer.  Many  cases 
presenting  lesions  of  tuberculosis,  actinomycosis,  mycosis  fungoides, 
sarcomatous  and  epitheliomatous  hyperplastic  tumors,  gout,  rheumatism, 
traumatism,  and  iodide  of  potassium  intoxication  have  been  paraded  as 
evidence  of  the  activity  of  the  syphilitic  virus  ten,  twenty,  thirty,  forty, 
and  fifty  years  after  infection. 

Tertiary  syphilis  attacks  the  following  tissues  and  organs :  the  skin 


TERTIARY  SYPHILIS.  601 

most  frequently  and  then  in  order  of  frequency  the  nervous  system,  the 
osseous  system,  mucous  membranes,  and  viscera  are  affected. 

Second  to  cutaneous  lesions  nervous  disturbances  are  most  frequent 
up  to  the  twentieth  year  of  infection,  and  after  that  date  they  are  very 
rare.    Syphilitic  myelopathies  are  very  rare  in  the  late  years  of  syphilis. 

Concerning  these  late  evolutions  of  tertiary  syphilis,  it  may  be  said 
that  in  many  cases  they  were  preceded  by  other  tertiary  lesions  more  or 
less  remotely  in  the  majority  of  cases.  In  very  exceptional  cases  there 
has  been  no  antecedent  tertiary  manifestation  whatever. 

AVhile  it  is  impossible  to  describe  sharply  marked  type-forms  of 
tertiary  syphilis,  a  generalization  of  cases  may  be  made. 

Cases  of  ulcerating  tubercular  syphilide  are  sometimes  seen  in  which 
the  lesions  begin  in  the  third  or  fourth  year,  sometimes  earlier.  I  have 
seen  some  rare  cases  in  which  these  syphilides  invaded  in  persistent  and 
interrupted  outbreaks  the  scalp,  the  face,  the  extremities,  and  the  trunk, 
producing  disfigurement  and  perhaps  mutilation  in  all  parts  attacked. 
Thus,  the  disease  kept  on,  in  spite  of  good  treatment,  for  years ;  then, 
after  an  interval  of  ten  years  of  apparent  health,  gummatous  infiltration 
and  ulceration  occurred,  and  the  skin  became  necrosed  at  slight  trauma- 
tisms. In  these  cases  syphilis  leaves  its  permanent  morbid  impress, 
with  a  tendency  to  hyperplasia  and  ulceration  of  the  skin,  for  years. 
In  some  occult  way  a  peculiarly  active  vulnerability  is  engrafted  on  the 
tissue. 

Then,  again,  we  see  cases  in  which  resolutive  tubercular  syphilides 
appear  on  one  region  and  remain  limited  to  it  for  a  long  time,  and  in 
the  course  of  ten  or  twenty  years  attack  most  of  the  integument  of  the 
whole  body.  In  these  cases  of  extensive  chronic  skin  lesions  the 
patients  may  enjoy  fairly  good  and  seemingly  robust  health.  In  some 
cases  intercurrent  nervous,  visceral,  osseous,  and  testicular  affections 
develop.  I  think,  however,  that  in  general  the  nervous  system  is  usu- 
ally spared  in  these  cases  of  extensive  tegumentary  invasion. 

Perhaps  one  of  the  most  frequent  forms  of  tertiary  syphilis  is  that 
in  which  the  serpiginous  syphilide  develops  upon  some  specific  lesion 
or  on  some  simple  ulceration  or  traumatism,  and  travels  over  certain 
regions  or  the  trunk  or  the  extremities.  Patients  thus  attacked  may 
be  thin  and  weakly,  or  even  robust  and  well  built.  This  lesion,  to 
my  mind,  indicates  rather  that  the  skin  of  the  patient  remains  vul- 
nerable to  microbic  invasion  than  that  it  is  an  evidence  of  the  activity 
of  the  syphilitic  diathesis. 

Some  cases  of  late  osseous  lesions  present  a  tolerably  uniform  course. 
Tims,  we  see  that  nodes  appear  on  the  skull  and  long  bones,  and  develop 
in  crops  at  irregular  intervals  for  years.  In  some  of  these  cases  there 
is  coexistent  joint-lesion,  and  in  some  men  testicular  involvement.     In 


602  TERTIARY  SYPHILIS. 

some  of  these  bone  cases  there  is  often  severe  and  persistent  rheumatism 
of  the  muscles  or  fibrous  tissues  and  a  markedly  cachectic  condition. 
These  patients  look  sallow  and  ill-nourished ;  their  faces  bear  the 
stamp  of  suffering;  they  suifer  from  malnutrition  and  from  insomnia 
the  result  of  pain.  In  these  cases  the  morbid  condition  is  very  chronic, 
and  very  rebellious  to  treatment. 

There  is  a  further  class  of  cases  of  tertiary  syphilis  which  present 
a  tolerably  well-defined  course.  The  patient  suffers  in  the  secondary 
period  with  rashes  and  meningeal  symptoms,  and  on  their  disappear- 
ance a  condition  of  impaired  health  supervenes.  This  may  last  years, 
and  then  the  patient  may  be  attacked  by  gummata  of  the  skin,  bones, 
or  testes,  or  he  may  develop  some  hyperplastic  or  arterial,  brain,  or 
cord  affection,  which  may  be  cured,  may  leave  him  a  cripple,  or  may 
kill  him. 

Cases  are  not  of  infrequent  occurrence  in  which,  after  a  faint 
and  ephemeral  or  a  well-developed  roseolous  syphilide,  an  interval  of 
seemingly  perfect  health  of  a  few  or  many  years  may  occur,  and  then 
cutaneous,  osseous,  testicular,  visceral,  or  cerebrospinal  symptoms  may 
develop. 

It  is  not  uncommon,  particularly  in  women  who  have  had  a  more 
or  less  severe  attack  in  the  secondary  stage,  to  observe  in  the  second 
and  third,  and  even  later,  years  of  the  infection  the  onset  of  cachexia 
and  a  gummatous  infiltration  into  the  hard  or  soft  palate,  which  may 
produce  much  destruction  of  tissue.  Very  commonly  these  are  the  only 
lesions,  but  in  some  cases  skin  and  bone  gummata  are  found  to  coexist. 

After  this  lugubrious  recital  of  these  grave  and  malignant  morbid 
conditions  due  to  tertiary  syphilis,  it  is  well  to  remember  that  in  the 
majority  of  cases  one  or  more  regions  and  one  or  several  organs  or 
tissues  may  be  attacked,  and  after  a  time,  under  the  influence  of  treat- 
ment, a  cure  is  induced. 

Though  tertiary  syphilis  is  severe  and  often  threatening  in  its  course, 
fortunately  for  the  human  race  it  is,  as  a  rule,  amenable  to  treatment 
in  a  marked  degree. 

It  is  claimed  by  some  authors  that  tertiary  syphilis  is  not  true  syph- 
ilis, but  a  chronic  morbid  condition  left  behind  by  the  active  infection. 
Other  authors  think  that  in  tertiary  syphilis  the  tissues  have  undergone 
some  changes,  and,  instead  of  reacting  normally  to  any  stimulus,  they 
produce  a  peculiar  growth  of  cells  known  as  gumma.  Seeing  that  ter- 
tiary lesions  may  coexist  and  follow  directly  in  the  wake  of  secondary 
manifestations,  that  the  pathological  processes  of  the  whole  disease  show 
a  distinct  gradation  and  an  intimate  correlation,  it  is  illogical  to  claim 
that  syphilis  can  stop  short  and  that  a  radically  different  morbid  con- 
dition  is   then  developed.     Clinical  observation    and    pathological  re- 


IGNORED  SYPHILIS.  603 

searches  show  very  conclusively  that  in  the  early  part  of  this  infection 
the  hyperemia  is  moderately  active,  and  that  the  cell-proliferations  are 
exuberant  and  widely  scattered.  In  the  late  stages,  on  the  contrary, 
the  cell-growth  is  slow  and  insidious,  and  shows  a  tendency  to  become 
localized  deeply  in  the  tissues  of  regions  and  organs. 

It  is  hard  to  explain  the  late  onset  of  connective-tissue  proliferation 
in  the  cerebrospinal  axis,  in  the  testis,  and  viscera  on  any  other  ground 
than  that  a  morbid  predisposition  or  impress  has  been  engrafted  on  the 
vessels  and  cells  of  these  parts  in  the  period  of  activity  of  the  infection, 
and  that  later  on,  owing  to  some  stimulation,  injury,  or  perhaps  excess 
of  function,  the  new  cell-growth  is  inaugurated. 

It  is  claimed  that  in  the  course  of  tertiary  syphilis  the  parotid,  the 
sublingual  thyroid  glands,  and  the  pancreas  may  be  attacked.  Cases 
of  these  affections  have  been  reported,  but  our  knowledge  of  them  is 
very  meagre. 

Etiology. — Lengthy  essays  have  been  written  on  the  etiology  of  ter- 
tiary syphilis,  but  the  essential  facts  can  be  briefly  stated.  Any  depraved 
condition  of  the  system  may  cause  the  secondary  period  of  syphilis  to  be 
prolonged,  and  to  be  followed  by  tertiary  manifestations.  Then,  again, 
the  tissues  of  some  persons  seem  to  be  so  profoundly  affected  by  syphilis 
that  the  infection  runs  its  full  course  in  them.  By  far  the  most  potent 
and  frequent  cause  of  tertiary  syphilis  is  the  absence  or  the  insufficiency 
of  treatment.  This  statement  almost  sums  up  the  case.  Marschalko, 
in  an  exhaustive  study  of  673  cases  of  tertiary  syphilis,  states  that,  as  a 
result  of  good  treatment,  tertiarism  was  found  in  only  2.7  per  cent., 
whereas  in  imperfectly  treated  cases  it  was  19.3  per  cent.,  and  under 
insufficient  treatment  it  reached  as  large  a  figure  as  23.9  per  cent. 

The  Infectiousness  of  Tertiary  Syphilis. — The  secretions  and 
tissue-detritus  of  precocious  and  quite  early  tertiary  lesions  contain  in- 
fectious qualities,  while  those  of  very  late  lesions  are  probably  inert. 
We  cannot,  to-day,  state  positively  when  syphilitic  lesions  lose  the 
power  of  infecting  healthy  persons. 


CHAPTER   XXXVIII. 

THE  TERTIARY  SYPHILIDES. 

THE  GUMMATOUS  SYPHILIDE. 

This  syphilide  is  almost  invariably  a  late  lesion,  and,  although  usually 
invading  the  skin,  it  always  begins  in  the  subcutaneous  connective  tissue. 
It  consists  of  tubercular  infiltrations,  some  as  small  as  a  pea  and  others 
several  inches  in  diameter.  When  great  extent  of  tissue  is  involved  the 
lesion  is  usually  composed  of  several  tumors  merged  together. 

This  syphilide  is  particularly  prone  to  appear  in  parts  where  the  con- 
nective tissue  is  loose  and  abundant.  It  may  be  limited  to  the  connec- 
tive tissue,  but  on  invading  the  skin  it  usually  ulcerates.  In  the  former 
case  we  apply  to  the  syphilide  the  term  gummous  or  gummous  tumor;  in 
the  latter  case  we  call  it  a  gummous  ulcer. 

The  progress  of  the  lesion  varies  according  to  the  condition  of  the 
parts  upon  which  it  is  developed  ;  in  thick  and  copious  adipose  or  cellu- 
lar tissue  the  tumors  may  remain  a  long  time  without  attacking  the  skin  ; 
under  contrary  conditions  or  overlying  a  bony  surface  implication  of  the 
skin  is  early  and  the  bone  itself  may  be  eroded  superficially  or  deeply. 
Sometimes  the  muscles  are  exposed  by  complete  destruction  of  super- 
jacent tissues.  Bloodvessels,  nerves,  and  sometimes  bursse  may  be  in- 
volved by  extension  of  the  lesion. 

We  shall  study  this  syphilide  in  its  three  stages — of  tumefaction,  of 
ulceration,  and  of  repair.  (For  the  description  of  precocious  gummata, 
see  page  561.) 

In  the  first  stage  we  find  from  one  to  six  tumors,  which  appear 
simultaneously  or  in  succession  and  run  an  indolent  course.  These 
small  tumors  are  painless  and  attended  by  slight  tenderness.  Their 
growth  is  generally  slow.  At  first  freely  movable,  they  soon  become 
attached  to  the  surrounding  tissues,  especially  when  seated  over  bony 
surfaces  or  in  regions  where  connective  tissue  is  scanty.  They 
give  to  the  finger  a  sensation  of  moderate  firmness,  retaining  their 
shape  under  pressure,  having  neither  the  elasticity  of  a  fatty  tumor  nor 
the  hardness  of  scirrhus.  In  many  cases  they  tend  to  invade  the  skin 
rather  than  the  deeper  tissues.  Their  superficial  growth  is  first  shown 
by  slight  reddening  of  the  overlying  skin,  which  rapidly  becomes  thick- 
ened and  less  supple.  Finally,  we  observe  a  tubercular  infiltration, 
round  or  oval  in  shape,  perhaps  slightly  elevated,  of  a  deep  coppery- 
red  color,  and  surrounded  by  a  well-marked  hypersernic  areola.      (See 

604 


THE  GUMMATOUS  SYPHILIDE.  605 

Fig.  145.)  They  may  remain  in  this  condition  for  many  weeks,  or  even 
months,  and,  still  under  treatment,  undergo  resolution.  Generally,  how- 
ever, their  firm  structure  slowly  breaks  down,  and  finally  fluctuation 
may  be  detected.  In  many  cases  the  soft,  yielding  character  of  the 
tumor  gives  a  false  impression  that  pus  is  confined  beneath  the  skin. 

Fig.  145. 


Gummatous  syphilide,  as  yet  unulcerated,  elephantiasic,  gummatous  condition  of  lower  leg. 

The  minute  changes  leading  to  this  condition  are  of  interest.  The 
immediate  product  of  the  death  of  the  subcutaneous  neoplasm  is  a  thick, 
gummy  mass,  the  intermingled  pus  being  supplied  by  the  surrounding 
parts,  which  are  secondarily  inflamed.  The  destructive  process  goes  on 
very  slowly  until  after  the  occurrence  of  ulceration.  The  small  ulcers 
first  formed  are  deep  and  sharply  cut;  they  extend  in  all  directions 
until  the  destruction  of  the  entire  neoplasm  results  in  the  formation  of 
what  may  be  called  a  typical  gummous  ulcer.  Such  an  ulcer  is  either 
round,  oval,  or  gyrate  from  fusion  of  the  small  ones,  and  sharply  cut  as 
if  punched  out.  Its  floor,  which  is  greenish-red  or  sometimes  greenish- 
black,  is  uneven  and  bathed  with  sanious  fetid  pus.  (See  Figs.  146 
and  147.) 


606 


THE  TERTIARY  SYPHIL1DES. 


Sometimes  the  integument  of  the  face  becomes  infiltrated  with  gum- 
matous tissue,  and  as  a  result  the  features  are  as  much  distorted  as  they 
are  by  leprosy,  and  have  a  decided  leonine  appearance. 

Gumma ta  not  infrequently  form  in  the  female  breast,  less  commonly 
in  both  breasts.  The  importance  of  their  diagnosis  is  here  very  great ; 
failure  to  recognize  their  true  character  may  lead  to  unnecessary  surgical 
interference.     They  appear,  as  elsewhere,  slowly ;  they  are  only  mode- 


Fig.  146. 


Gummatous  syphilide. 

rately  hard,  and  are  painless.  There  is  no  retraction  of  the  nipple,  and 
the  axillary  glands  are  unaifected.  The  ulceration  which  occurs  is 
characteristic  and  quite  unlike  the  indurated,  fungoid  ulceration  of  cancer. 
In  all  cases  of  limited  tumors  of  the  breast  a  suspicion  of  their  gumma- 
tous character  should  be  entertained,  especially  when  the  patient  is 
young  or  of  middle  age.  A  mistake  is  liable  to  occur  only  when  the 
gumma  is  very  large  and  of  unusual  depth. 


THE  GUMMATOUS  SYPHTLIDE.  607 

Gummata  are  very  frequently  diagnosticated  as  sarcomatous  tumors, 
and  many  cases  are  on  record  in  which  they  have  needlessly  been 
removed  by  the  knife. 

The  cicatrices  of  gammons  ulcers  differ  according  to  the  depth  of  the 
destructive  process.  "When  the  ulceration  has  been  superficial  the  scars 
are  slightly  depressed,  thin,  parchment-like,  and  of  a  dead-white  color. 
All  such  cicatrices  become  blanched  from  their  centre  outward. 

The  cicatrices  of  deep  ulcers  are  much  depressed,  and  often  very  un- 
even, owing  to  fibrous  bands  and  nodules.  Some  are  also  peculiar  in 
being  adherent  to  the  deeper  parts.  In  case  the  gummous  ulceration  has 
involved  the  superficial  portion  of  the  bone,  the  cicatrix  adheres  as  firmly 
as  did  the  periosteum  to  the  osseous  surface.  In  other  cases  where  much 
destruction  of  bone  has  occurred  no  cicatrix  at  all  is  formed,  the  eroded 
surface  being  surrounded  by  a  firmly  attached  fibrous  band  which  repre- 
sents the  margin  of  what  might  have  been  a  cicatrix. 

Fig.  147. 


Gummatous  infiltration  over  the  wrist  and  dorsum  of  the  hand. 

Gummy  tumors  present  certain  peculiarities  in  different  regions  of 
the  body,  and  may  be  complicated  by  intercurrent  morbid  processes. 
Erysipelas  may  attack  the  ulcers,  especially  when  seated  on  the  head  or 
extremities.  The  oedema  which  accompanies  gummous  ulcers  of  the  leg 
may  be  so  severe  and  chronic  as  to  induce  a  condition  similar  to  elephan- 
tiasis Arabum. 

Gummy  tumors  of  the  scalp  are  seldom  isolated  and  movable ; 
usually  the  entire  integument  is  thickened,  and,  although  at  first  movable 
over  the  bones,  soon  becomes  adherent.  Small  ulcers  form  at  follicular 
openings,  and  gradually  increase  in  size.  Sometimes  the  outer  table  of 
the  skull  is  destroyed,  and  in  other  cases  the  whole  thickness  of  bone 
becomes   necrosed  ;    the  dura   mater,  however,   resists   the   destructive 


608  THE  TERTIARY  SYPHILIDES. 

action  in  a  remarkable  manner,  and  is  rarely  involved.  The  scalp  over 
the  frontal  and  parietal  bones  is  most  commonly  attacked,  and  not  in- 
frequently the  forehead,  chiefly  toward  the  median  line,  is  invaded. 

The  course  of  such  ulcers  varies  with  the  care  they  receive.  They 
may  remain  in  an  indolent  condition  for  months,  discharging  a  foul 
secretion,  showing  no  reparative  tendency,  and  inducing  great  oedema 
of  surrounding  parts. 

The  depth  of  the  ulcers  depends  largely  upon  the  thickness  of  the 
original  infiltration.  In  some  cases  the  gummy  deposit  is  confined  to 
the  cellular  tissue  just  below  the  papillary  layer  of  the  skin,  and  the 
resulting  ulcer  is  relatively  shallow.  In  other  cases  it  is  more  deeply 
seated  below  the  derma,  and  may  be  exposed  by  scraping  off  the  upper 
layers. 

Gummata  may  be  situated  in  almost  any  region  over  a  nerve,  and 
may  then  cause  pain. 

The  prognosis  is  influenced  by  the  date  of  the  appearance  of  the 
syphilide,  its  extent,  and  the  general  condition  of  the  patient.  Its  early 
and  malignant  appearance  indicates  an  active  and  severe  form  of  syph- 
ilis, in  which  visceral  gummata  are  to  be  feared. 

The  diagnosis  is  to  be  made  in  its  stages  of  tumefaction  and  of 
ulceration.  When  it  exists  as  a  movable,  subcutaneous  tumor  it  may 
be  mistaken  for  a  fibrous,  a  sarcomatous,  or  a  fatty  tumor,  or  perhaps 
an  enlarged  ganglion.  The  syphilitic  lesion  is  usually  multiple,  and  is 
not  compressible  like  the  fatty  tumor  nor  as  hard  as  the  sarcoma.  Sar- 
comata tend  to  attach  themselves  to  subjacent  parts;  the  gummy  tumors 
invade  the  skin.  The  history  of  the  case,  the  absence  of  pain  in  the 
tumor,  and  its  situation  may  be  of  assistance.  Tumor-like  infiltrations 
upon  the  face,  in  the  female  breast,  about  the  genitals,  near  joints,  and 
wherever  connective  tissue  is  abundant  should  always,  in  case  of  doubt, 
be  subjected  to  specific  treatment. 

The  general  appearance,  situation,  and  history  of  gummatous  ulcers 
are  generally  sufficient  to  establish  their  character;  but  sometimes,  espe- 
cially on  the  face  and  lower  extremities,  they  may  be  confounded  with 
ulcerating  lupus  or  with  simple  eczematous  or  varicose  ulcers. 

Subcutaneous  nodular  infiltrations  which  resemble  in  nearly  all  their 
features  gummata  are  sometimes  seen,  particularly  in  weakly  and  so- 
called  strumous  subjects.  These  nodules,  called  erythemZ  induri  des 
scrofuleux,  and  gommes  scrofuleuses,  may  be  of  the  size  of  a  pea  or  of  a 
hazelnut  or  walnut,  and  they  may  exist  in  the  form  of  diffuse  plaques. 
They  run  a  chronic  course,  they  contract  adhesions  with  the  skin,  and 
they  may  lead  to  ulceration.  In  all  particulars  these  lesions  as  to 
physical  appearances,  site  of  development,  and  course  resemble  syph- 
ilitic gummata.     They  occur  most  frequently  in   young  subjects,  and 


THE  TUBERCULAR  SYPHILIDE.  609 

rather  rarely  in  older  persons.  In  some  of  these  cases  antisyphilitic 
treatment  proves  beneficial  even  when  a  history  of  syphilis  cannot  be 
obtained. 

Treatment. — In  all  cases  a  vigorous  mixed  treatment  should  be 
persisted  in.  When  ulceration  is  active  it  may  be  necessary  in  some 
cases  to  scrape  away  its  base  and  margin.  The  necrotic  membrane  so 
commonly  seen  in  these  ulcers  should  be  treated  with  gauze  compresses 
of  sublimate  solution  (1  :  2000  to  1 :  500),  or  with  compresses  of  carbolic- 
acid  solution  (5  per  cent.).  The  application  of  carbolic  acid  or  nitric 
acid  may  be  necessary  every  few  days  to  remove  necrotic  matter. 
When  the  slough  or  membrane  on  the  surface  of  the  sore  is  not  very 
dense  or  adherent,  iodoform  may  be  dusted  upon  it.  When  a  raw  sur- 
face has  been  exposed  the  application  of  a  mild  mercurial  ointment 
with  the  addition  of  balsam  of  Peru  (1  drachm  to  the  ounce)  will  usually 
cause  prompt  healing. 

THE  TUBERCULAR  SYPHILIDE. 

This  syphilide  consists  of  deeply  seated,  circumscribed  infiltrations 
into  the  skin,  resembling  in  appearance  the  large,  flat,  papular  syphilide, 
and  being,  in  reality,  nothing  more  than  an  exaggerated  form  of  the 
latter  lesion.  The  whole  thickness  of  the  skin  is  involved,  whereas  in 
the  papular  syphilide  the  deeper  layers  escape ;  the  latter  is  a  secondary 
manifestation,  while  the  tubercular  syphilide  is  a  tertiary  lesion. 

The  tubercular  syphilide  seldom  ulcerates,  but  disappears  by  inter- 
stitial absorption  ;  hence  it  has  been  called  non-ulcer utive  or  resolutive. 

The  resolutive  tubercular  syphilide  may  appear  even  before  the 
second  year  of  syphilis  ;  it  is  usually  developed  between  the  third  and 
sixth  years,  but  may  be  seen  as  late  as  the  eighth  or  tenth  year,  and, 
according  to  some  authors,  even  as  late  as  the  fifteenth  or  twentieth. 
It  is  usually  met  with  in  cases  that  have  not  been  thoroughly  treated 
at  the  outset.  Its  course  is  very  chronic  and  marked  by  numerous 
relapses. 

The  tubercles  begin  as  deep-red  spots,  which  slowly  increase  in  size 
and  thickness  until,  when  fully  developed,  they  have  a  diameter  of  from 
half  an  inch  to  an  inch.  Sometimes  they  are  as  small  as  a  split  pea, 
and  again  they  are  more  than  an  inch  in  diameter.  Their  surface  is  flat 
or  rounded,  and  their  borders  are  sharply  defined.  The  smaller  lesions 
are  more  elevated  and  rounded  than  the  larger.  The  color  of  the 
tubercles  is  at  first  dark  red,  with  possibly  a  tinge  of  crimson,  but  fre- 
quently it  is  of  a  light  pinkish  red.  Their  surface  is  usually  smooth 
and  free  from  scales.  Where  the  epidermis  is  thick  proliferation  is 
occasionally  free,  giving  the  tubercles  somewhat  the  appearance  of 
psoriasis. 

39 


610  TEE  TERTIARY  SYPEILIDES. 

The  tubercles  first  appear  on  the  forehead  or  back  of  the  neck  near 
the  scapulae.  They  may  be  limited  to  these  regions  or  may  invade  the 
trunk,  always  more  copiously  on  the  back  and  over  the  gluteal  regions. 
In  frout  they  are  generally  scattered,  but  in  some  cases  they  occur  in 
large  numbers  over  the  sternal  region,  on  the  borders  of  the  axilla?,  and 
over  the  deltoid  muscle.  They  are  more  numerous  on  the  outer  aspects 
of  the  extremities  near  the  joints  than  on  the  inner. 

The  course  of  the  eruption  is  very  slow ;  several  weeks,  or  even 
months  and  years,  may  pass  before  the  entire  body  is  covered.  When 
the  eruption  is  general  the  tubercles  are  usually  disseminated  without 
order,  rarely  showing  a  tendency  to  circular  distribution.  Successive 
crops  fill  the  interspaces  between  those  first  developed.  When  preco- 
cious the  eruption  may  be  very  copious.  In  several  of  the  cases  I  have 
seen  of  recurrence  of  this  eruption  the  tubercles  were  almost  in  contact 
with  each  other.  Such  cases  are  rare,  and  belong  to  the  group  of  malig- 
nant precocious  syphilides. 

These  tubercles  are  prone  to  appear  in  an  irregularly  triangular 
group,  with  the  apex  at  the  glabella  and  the  base  near  the  margin  of 
the  scalp.  They  may  form  a  sort  of  corona  in  the  latter  regions  with 
sometimes  a  number  on  the  scalp  itself.  On  the  face  they  sometimes 
run  together  and  form  patches.  Again,  several  tubercles  on  the  nose 
blend  and  extend  to  the  cheeks,  forming  a  butterfly-shaped  patch. 
When  the  tubercles  spread  in  a  rapid  manner  a  distinctly  elevated 
margin  or  rim  is  formed,  the  enclosed  patch  being  depressed.  In  this 
serpiginous  form  the  whole  face  may  become  invaded.  The  centre  of 
the  patch  gradually  loses  its  color  and  becomes  thinner,  until  in  severe 
cases  a  cicatricial  tissue  is  left.  This  process  is  usually  rapid,  and  then 
slight  destruction  of  the  skin  results ;  when  it  is  slow  more  or  less 
atrophy  of  the  skin  is  produced.  This  may  be  called  the  annular  tuber- 
cular syphilide.     (See  Plate  XXXVIII.) 

These  tubercular  rings  are  not  seen  in  all  cases  ;  in  some  the  lesion 
extends  merely  at  certain  portions  of  its  margin.  Thus,  kidney-shaped 
growths  are  produced,  or  new  tubercles  may  form  and  finally  coalesce 
around  the  entire  periphery  of  the  patch.  Tubercular  patches  seated 
on  non-hairy  parts  are  smooth,  while  those  developed  in  regions  sup- 
plied with  hair  are  often  uneven  and  warty.  The  latter  condition  is 
due  to  fusion  of  the  tubercles  and  excessive  prominence  of  the  follicles 
and  papillse.  Their  surface  may  be  covered  with  a  crust  of  serum  and 
epidermis,  or  the  scanty  pus  may  dry  between  the  numerous  elevations. 
Cases  of  invasion  of  the  entire  scalp  in  this  way  have  been  recorded, 
and  doubtless  many  of  the  cases  of  framboesia  of  the  old  writers  were 
aggravated  instances  of  this  vegetating  or  papillomatous  tubercular 
syphilide.      The   papular   syphilide   may  undergo  a   similar  metamor- 


PLATE  XXXV1I1. 


THE    ANNULAR    TUBERCULAR    SYPHILIDE. 


THE  TUBERCULAR  SYPHILIDE. 


611 


phosis.  We  have,  therefore,  two  kinds  of  vegetating  or  papillomatous 
svphilide — a  papular  and  a  tubercular — which  differ  merely  in  degree. 
The  head  and  face  are  most  commonly  attacked,  but  the  trunk  about  the 
shoulders,  over  the  sternum,  and  in  the  inguinal  and  gluteal  regions 
may  be  invaded.  When  this  svphilide  is  thus  altered  in  character  its 
course  is  more  chronic  than  usual.  The  papillomatous  or  vegetating 
appearance  of  this  form  of  tubercular  syphilide  is  due  to  the  exuberant 

Fig.  148. 


The  late  variety  of  the  vegetating  syphilide,  showing  its  annular  form  and  its  serpiginous 

tendency. 

new  cell-growth  in  the  papillse,  which  become  greatly  hypertrophied. 
(See  Figs.  148  and  149.) 

The  course  of  the  eruption  depends  largely  upon  treatment.  In 
its  early  stages  it  will  usually  be  dispersed  by  vigorous  measures.  A 
limited  relapse  is  very  likely  to  occur  in  case  of  inadequate  treatment. 

The  prognosis  of  this  syphilide  is  good,  although  it  indicates  an 
active  and  persistent  form  of  syphilis. 

Diagnosis. — This  syphilide  is  to  be  diagnosed  from  lupus  vulgaris, 
elephantiasis  Grsecorum,  carcinoma,  and  psoriasis.  Lupus  generally 
begins  in  early  life,  and  is  never  so  diffusely  scattered  as  the  tubercular 


612 


THE  TERTIARY  SYPHILIDES. 


syphilide.  The  resemblance  is  seldom  striking  except  when  the  latter 
is  limited  to  the  face.  Lupus-tubercles  are  usually  more  irregular  in 
outline  and  deeper  than  those  of  syphilis.  They  are  pinkish-red  rather 
than  brownish-red,  as  in  the  latter  disease. 

Fig.  149. 


Vegetating  syphilide  of  dorsum  of  foot. 

In  some  cases  of  true  leprosy  tubercles  occur  which  resemble  in 
size,  shape,  and  color  those  of  syphilis,  but  they  are  usually  accom- 
panied by  white,  anaesthetic  patches,  large  spots  of  brown  pigmentation, 
nerve-swellings  with  perverted  sensations,  large  nodular  infiltrations 
and  ulcerations,  or  other  manifestations  which  characterize  leprosy. 

Although  superficial  carcinomatous  tubercles  may  resemble  those  of 
syphilis,  they  are  never  so  scattered,  and  are  always  much  larger, 
sometimes  involving  an  entire  region. 

The  tubercular  syphilide  occasionally  presents  two  appearances 
which  resemble  psoriasis.  The  first  is  when  the  tubercles  are  covered 
with  an  unusual  number  of  scales,  especially  on  the  outer  aspect  of  the 
arms,  where  psoriasis  is  prone  to  appear.  The  second  is  when  the 
tubercles  undergo  involution  and  form  rings.  Psoriasis,  however,  is  a 
disease  beginning  in  youth,  and  is  essentially  scaly.  The  tubercles  of 
syphilis  are  infiltrations,  and,  though  some  may  be  covered  with  scales, 
others  will  be  found  free  from  them.  In  syphilis,  again,  we  have  the 
history  of  the  case  and  perhaps  other  manifestations  of  the  disease. 
In  rare  cases  in  which  the  eruption  is  limited  and  the  history  obscure 
mercurial  treatment  settles  all  questions,  since  it  cures  a  syphilide  and 
does  not  influence  psoriasis. 

Treatment. — Inunctions  of  mercurial  ointment  should  be  regularly 
administered  and  iodide  of  potassium  in  good-sized  doses  should  be 
taken  internally.  The  mixed  treatment  is  also  very  beneficial.  Mer- 
curial fumigations  are  often  of  surprising  benefit  in  causing  the  prompt 
involution  of  this  syphilide. 


THE  SERPIGINOUS  SYPHILIDE. 


61; 


THE  SERPIGINOUS  SYPHILIDE. 

This  syphilide  creeps  over  large  surfaces  by  ulcerating  at  the  periph- 
ery of  patches  while  it  heals  in  the  centre.  It  may  occur  as  early 
as  the  second  or  as  late  as  the  tenth  or  fifteenth  year  of  syphilis,  pos- 
sibly later.  Its  course  is  very  chronic,  and,  although  unattended  by 
pain,  it  frequently  causes  great  inconvenience.  Its  effects  on  the  skin 
may  be  slight  or  it  may  leave  disfiguring  cicatrices.  There  are  two 
varieties  of  this  lesion,  a  superficial  and  a  deep. 

The  superficial  serpiginous  syphilide  begins  as  a  pustule,  generally 
of  the  impetigoform  or  of  the  variolaform  syphilide.  In  its  early  stage 
it  consists  of  a  superficial  ulceration,  which  has  no  characteristic  feat- 
ures indicative  of  its  future  course,  but  which  extends  in  the  shape  of 
a  round  or  oval  patch.  If  treatment,  and  particularly  local  treatment, 
is  not  employed,  the  process  continues  and  crusts  form  until  the  patch 
reaches  a  diameter  of  about  two  inches  ;  granulations  then  spring  up 
from  the  centre,  and  the  crust  falls  off  except  at  the  periphery,  where 
it  adheres  as  an  encircling  ring.  Thus  is  formed  a  ring  of  crusts 
enclosing  a  more  or  less  hypereemic  area  of  a  round  or  oval  shape. 
(See  Fig.  150.)  The  color  of  the  crusts  is  usually  yellowish -brown  or 
greenish-black,  and  their  thickness  about  one-third  of  an  inch.  The 
underlying  surface  is  smooth,  of  a  grayish-red  color,  and  ulcerated  at 
the  margins.  Around  the  edges  is  a  narrow  red  areola.  The  ulcera- 
tive process  slowly  progresses  at  the  margins  of  the  patch,  a  rim  of 


The  superficial  serpiginous  syphilide.    The  area  of  skin  enclosed  (over  elbows)  within  the  rings 
of  crusts  is  pigmented,  but  not  at  all  cicatricial  in  character. 


crust  at  the  same  time  forming.  Healing  of  the  enclosed  surface  keeps 
pace  with  the  peripheral  extension  of  the  ulceration,  so  that  the  width 
of  the  crust,  varying  from  half  an  inch  to  an  inch,  is  steadily  main- 
tained. The  centre  of  this  surface  is  blanched;  its  margins  are  red, 
and  they  merge  gradually  into  the  ulceration.  This  process  may 
continue  many  years  and  involve  extensive   surfaces.     When  healing 


614 


THE  TERTIARY  SYPHILIDES. 


begins  the  crusts  become  harder  and  darker,  and  the  redness  of  the 
central  patch  and  of  the  areola   diminishes. 

The  deep  serpiginous  syphilide  has  for  its  focus  of  ulceration  one  of 
the  late  or  tertiary  lesions,  such  as  a  tubercle,  an  ecthymaform  pustule, 
an  ulcerating  gumma,  or  some  traumatism.  Whatever  the  starting- 
point,  there  is  soon  developed  a  deep,  sharply  cut  ulcer  with  under- 
mined edges  and  a  coextensive  crust.  This  ulcer  slowly  or  rapidly 
increases  in  size  until  it  attains  a  diameter  of  two  or  three  inches, 
when  changes  similar  to  those  observed  in  the  superficial  variety  may 
occur.  The  crust  becomes  thin  at  its  centre  and  thick  at  its  margin  ; 
the  thin  portion  soon  falls  oif,  leaving  a  round,  deep-red  cicatrix,  sur- 
rounded by  a  thick,  greenish-black  crust  less  than  an  inch  in  width. 
When  this  syphilide  is  fully  developed  and  has  attained  a  diameter  of 
from  four  to  six  inches,  its  appearances  are  more  marked.  (See  Fig. 
151.)  In  the  centre  is  a  round  or  oval  patch  of  cicatricial  tissue  having 
a  coppery-red  color,  and  firmly  attached  to  the  subcutaneous  connective 
tissue.     This  is  completely  enclosed  by  a  ring  of  crust  which  grows 


Ftg.  151. 


The  deep  serpiginous  syphilide,  showing  much  cicatrization  of  the  abdominal  wall. 

steadily  outward  and  may  become  very  large.     The  enclosed  cicatricial 
area  keeps  pace  in  size  with  the  increase  of  the  encrusted  ring. 
Relapses  may  occur  from  ulceration  of  the  cicatrix. 


RUPIA,    OR   THE  RUPIAL  SYPHILID E.  615 

The  course  of  this  syphilide  is  always  slow,  often  occupying  many 
years.  In  some  cases  it  is  accompanied  by  profound  cachexia,  while  in 
others  there  is  no  disturbance  of  the  general  health. 

This  syphilide  is  of  rare  occurrence.  It  may  appear  as  early  as  the 
third  year,  but  generally  later,  even  up  to  the  fifteenth  year  after  infec- 
tion. It  appears  usually  on  the  inner  surface  of  the  forearms  and 
arms,  on  the  breast,  and  on  the  legs.  It  causes  little  if  any  pain,  but 
frequently  gives  great  annoyance  when  near  the  joints. 

The  prognosis  of  this  syphilide  depends  entirely  upon  the  institu- 
tion of  general  and  local  treatment  which,  aided  by  tonics  and  good 
hygiene,  will  produce  a  prompt  cure. 

The  diagnosis  from  serpiginous  lupus  and  serpiginous  chancroid  is 
seldom  difficult.  Lupus  usually  begins  in  early  life,  and  attacks  the 
face.  Its  ulcerations  are  less  definite  and  sharply  cut  than  those  of 
the  syphilide.  In  lupus  red  tubercles  of  ulceration,  covered  with  crusts 
of  light-yellow  or  bluish-brown,  are  mingled  with  the  cicatrices,  which 
are  always  uneven  and  fibrous.  The  history  of  the  case  may  add  to 
the  certainty  of  diagnosis. 

A  serpiginous  chancroid  usually  has  such  a  clear  history  that  no  mis- 
take can  occur. 

Treatment. — The  crusts  must  be  removed  by  means  of  hot  bichloride 
compresses.  The  ulcers  should  be  well  cauterized  with  pure  carbolic 
acid,  after  which  bichloride  gauze  may  be  used  for  a  time.  Then  the 
parts  are  to  be  covered  with  mercurial  ointment.  Internally  the  mixed 
treatment  should  be  given. 

RUPIA,  OR  THE  RUPIAL  SYPHILIDE. 

This  name,  derived  from  the  Greek  puTzoz,  dirt,  is  applied  to  an  erup- 
tion composed  of  ulcers  surmounted  by  laminated  crusts.  It  appears 
sometimes  precociously  during  the  first  year  of  syphilis,  but  it  belongs 
among  the  late  lesions.  It  usually  indicates  intense  syphilitic  infec- 
tion, and  is  often  accompanied  by  fever.  It  has  never  been  seen  in 
hereditary  syphilis.  Although  a  pustulo  crustaceous  eruption,  it  par- 
takes of  the  nature  of  tertiary  lesions  in  the  deep-seated  infiltration 
always  present  beneath  the  crusts. 

Rupia  may  be  divided  into  two  varieties  :  one,  in  which  the  crusts 
are  small,  numerous,  and  generally  scattered  ;  another,  in  which  they 
are  large,  less  numerous,  and  more  localized.  All  of  the  lesions  of 
rupia  begin  as  a  red  spot,  which  soon  becomes  a  flat  pustule  which 
dries  into  a  greenish-brown  crust.  Subsequent  changes  are  very  slow. 
The  initial  crust  is  usually  small,  and  underneath  it  is  a  superficially 
ulcerated,  infiltrated  surface.  The  infiltration  and  ulceration  extend 
somewhat  beyond  the  original  crust,  and  another  layer  of  crust  is  formed 


616 


THE  TERTIARY  SYPH1LIDES. 


beneath  it  by  the  secretion  from  the  ulcerated  surface.  Thus  several 
distinct  but  adherent  laminations  are  formed  as  the  ulcer  increases  in 
size,  each  succeeding  one  being  larger  than  its  predecessor.  This  result 
is  mainly  due  to  the  fact  that  the  pus  is  thick,  and  that  it  is  secreted 
slowly  and  dries  quickly.  The  process  may  continue  until  the  crusts 
attain  a  diameter  of  half  an  inch  or  even  two  inches.  (See  Fig.  152.) 
In  rare  cases  they  have  been  seen  with  a  diameter  of  fully  six  inches. 
When  developed  the  rupial  crust  is  conical,  distinctly  laminated,  and 
of  a  brownish-black  color  tinged  with  green,  similar  to  a  dirty  oyster- 
shell.  The  crust  is  hard,  firm,  and  adherent,  although  its  layers  are 
often  perfectly  distinct.  Underneath  there  is  an  unhealthy,  grayish- 
red,  ulcerated  surface  bathed  in  thick,  ichorous  pus  and  surrounded  by 
a  slightly  undermined  margin.  The  depth  of  this  ulcer  is  rarely  so 
great  as  that  of  the  severe  ecthymaform  syphilide.  It  generally  involves 
about  one-half  the  thickness  of  the  derma.  Around  each  ulcer  is  a 
coppery-red  areola,  which  merges  into  healthy  tissue. 

Fig.  152. 


Rupia,  or  rupial  syphilide. 


The  small  rupial  eruption  begins  either  about  the  face  or  on  the  inner 
and  outer  surfaces  of  the  forearms.  It  may  then  invade  the  trunk  and 
lower  extremities. 

The  eruption,  composed  of  large  crustaceous  ulcers,  usually  presents 
a  limited  number  of  lesions.  Exceptionally  we  find  only  one  crust,  but 
in  some  cases  as  many  as  twenty  or  thirty.  They  resemble  those  of  the 
small  variety.  Under  proper  treatment  the  ulcer  slowly  heals,  until  a 
deep-red  glazed  infiltration  is  left,  which  gradually  becomes  thinner  and 
lighter-colored,  and,  finally,  a  white,  shining    surface  is  left,  which  is 


THE  BULLOUS  SYPHILIDE.  617 

depressed  below  the  general  level,  and  around  which  a  rim  of  brown 
pigment  remains  for  months,  corresponding  to  the  former  areola. 

The  prognosis  of  rupia  is  to  be  guardedly  given.  In  some  rare 
cases  of  precocious  evolution  this  eruption  becomes  general,  the  lesions 
being  large  and  numerous,  and  the  general  condition  being  at  the  same 
time  much  depressed.  Without  careful  and  vigorous  treatment  this 
malignant  form  of  syphilis  may  be  fatal.  The  small  generalized  form 
of  rupia,  although  accompanied  by  cachexia,  may  be  cured  in  a  few 
weeks.     The  ulcers  usually  occasion  much  annoyance  and  suffering. 

The  large  form  of  rupia  is  of  considerable  gravity  and  calls  for  ener- 
getic local  and  constitutional  treatment.  Although  many  cases  recover, 
death  sometimes  occurs. 

A  question  of  diagnosis  is  not  liable  to  arise,  since  no  simple  erup- 
tion resembles  rupia. 

Treatment. — This  syphilide  should  be  treated  after  the  manner 
laid  down  for  the  serpiginous  syphilide.  It  is  very  important  that  the 
nutrition  of  the  patient  should  be  carefully  looked  after. 

THE  BULLOUS  SYPHILIDE. 

Much  confusion  has  been  introduced  into  syphilography  by  the  lati- 
tude given  to  the  term  "  pustule."  From  the  fact  that  some  forms  of 
syphilitic  pustules  are  not  situated  upon  an  elevated  base  and  are  large 
and  globular,  with  a  tendency  to  run  together,  the  existence  of  a  true 
pemphigoid  syphilide  has  been  asserted.  Further  study  has  proved 
these  lesions  to  be  pustular,  and  not  bullous,  yet  in  some  cases  true  bullae 
are  developed  on  syphilitic  patients. 

The  eruption  begins  like  ordinary  pemphigus  by  an  effusion  of  serum 
beneath  the  epidermis,  which  slowly  increases,  until  at  the  end  of  a  week 
or  two  a  bulla  the  size  of  a  pea  is  formed.  The  serum  soon  becomes 
milky,  and  is  finally  converted  into  a  thick  yellow  pus.  The  bulla? 
vary  in  size,  some  being  as  large  as  a  walnut.  They  are  surrounded 
by  a  dull-red  areola,  which  on  the  legs  may  be  due  to  effusion  of  blood. 
The  pus  soon  dries  into  a  dark,  greenish-black,  adherent  crust. 

This  eruption  occurs  mostly  on  the  forearms  and  legs,  where  it  may 
be  aggregated.  When  it  invades  the  trunk  it  is  more  extensive  about 
the  chest,  but  is  generally  discrete.  Its  invasion  is  usually  very  slow. 
Its  course  is  also  very  chronic  and  unattended  by  marked  symptoms, 
except  soreness  and  sometimes  heat  in  the  bulla?  and  ulcers.  New 
bulla?  may  form  during  the  course  of  the  eruption  or  after  it  has  once 
disappeared. 

The  bullous  syphilide  is  almost  always  a  late  eruption. 

Prognosis. — This  syphilide  usually  occurs  in  debilitated  subjects, 
therefore  the  cure  may  be  delayed. 

The  treatment  is  similar  to  that  of  the  serpiginous  syphilide. 


CHAPTER   XXXIX. 

SYPHILITIC  AFFECTIONS  OF  THE  TONGUE,  THE  SOFT  PALATE, 

THE  PHARYNX,  THE  LARYNX,  AND  THE 

CESOPHAGUS. 

THE  TONGUE. 

In  late  secondary  and  in  tertiary  syphilis  the  tongue  may  be  the  seat 
of  sclerosis  and  of  gummata. 

Sclerosis. 

Sclerosis  of  the  tongue  is  most  frequent  about  the  fifth  year  of 
syphilis.  It  is  usually  developed  near  the  median  line,  and  always  on 
the  upper  surface  of  the  tongue,  and  may  be  superficial  or  deep. 

Superficial  sclerosis  involves  the  mucous  membrane  only,  and  pro- 
duces a  lamellated  induration  analogous  to  the  "  parchment"  induration 
of  the  chancre.  It  may  be  circumscribed  or  diffuse,  and  ulcerates  only 
as  a  result  of  injury  by  the  teeth,  tobacco,  or  similar  irritants. 

Parenchymatous  or  deep  sclerosis  may  be  considered  an  aggravated 
form  of  the  superficial  lesion,  and  invades  the  muscular  as  well  as  the 
mucous  tissue.  The  tongue  may  be  greatly  increased  in  size,  but  after 
long  persistence  of  the  lesion  the  newly  formed  fibrous  tissue  retracts, 
and,  as  in  cirrhosis  of  other  organs,  atrophy  results.  At  first  the  hyper- 
trophied  tongue  receives  the  imprint  of  the  teeth  at  its  margin,  the  body 
of  the  organ  being  lobulated  in  a  manner  almost  pathognomonic.  The 
lobules  are  separated  by  furrows  which  cannot  be  effaced  by  stretching, 
in  this  respect  offering  a  contrast  with  the  ruga?  which  occur  on  the 
tongue  in  dyspepsia  and  other  depraved  conditions  of  the  system.  The 
induration  is  deep  and  cartilaginous,  and  the  mucous  membrane  becomes 
changed  in  color  and  perfectly  smooth.  Ulceration  may  result  from 
causes  similar  to  those  which  produce  it  in  the  milder  form  of  sclerosis. 
When  parenchymatous  sclerosis  involves  the  whole  tongue — which, 
fortunately,  it  seldom  does — the  tumefaction  may  be  enormous.  (See 
Plate  XXXIX.) 

Gummata. 

Like  scleroses,  gummata,  which  are  later  lesions,  may  be  designated 
as  superficial  or  parenchymatous,  since  they  may  be  found  in  the  mucous 
or  the  muscular  tissue  of  the  tongue. 

The  superficial  or  mucous  gumma  begins  as  a  small  nodule,  which 
618 


PLATE   XXXIX. 


PARENCHYMATOUS    SCLEROSIS    OF    THE    TONGUE. 


GUMMATA.  619 

soon  softens  and  ulcerates,  leaving  an  excavation  with  perpendicular 
margins  and  an  infiltrated  base,  which  is  often  covered  by  tenacious 
false  membrane  of  a  yellowish-white  color. 

Parenchymatous  gummata  are  developed  in  the  muscular  tissue  of  the 
tongue,  taking  their  origin  in  the  connective  tissue.  They  begin  as  small 
tumors,  which  are  sometimes  difficult  of  detection  on  account  of  their 
depth  and  of  the  surrounding  induration.  The  process  of  degeneration 
extends  from  the  middle  of  the  tumors  until  the  thinned  mucous  mem- 
brane over  them  on  the  upper  surface  of  the  tongue  becomes  ruptured, 
exposing  a  deep  cavity  with  overhanging  and  sloughy  walls,  surrounded 
by  an  areola  of  induration.  In  view  of  the  great  size  of  the  cavity, 
one  would  expect  excessive  deformity,  but  cicatrization  often  takes  place 
with  relatively  slight  permanent  damage.  In  rare  cases  two  or  more 
gummatous  tumors  coalesce,  and  lead  to  enormous  enlargement  of  the 
tongue  and  proportionate  destruction  of  its  tissue.  The  ulcers  may  be 
attacked  by  phagedena,  when  the  condition  becomes  more  severe. 
Without  treatment  these  ulcers  are  remarkably  chronic.  One  has 
been  reported  which  persisted,  with  comparatively  little  change,  for 
twenty  years.  Gummatous  tumors  occasionally  undergo  calcific  degen- 
eration. 

Their  insidious  formation,  their  seat  at  the  sides  and  toward  the  tip 
of  the  tongue,  their  chronic  course,  and  their  freedom  generally  from 
spontaneous  pain  are  characteristic  features  of  gummatous  tumors.  The 
observation  of  Anger,  that  lancinating  pain  shooting  toward  the  ear  is 
diagnostic  of  cancer  of  the  tongue,  has  been  repeatedly  confirmed. 
Gummatous  tumors  may  appear  at  a  period  much  earlier  than  is  usual 
with  cancerous  nodules.  A  gumma  begins  as  a  nodule  which  breaks 
down  ;  epithelioma,  as  a  firm,  a  warty,  or  an  exuberant  growth.  In 
addition  to  these  facts,  and  to  the  individual  and  family  antecedents 
of  a  patient,  the  ulcerating  surfaces  of  the  tumors  present  somewhat 
constant  features  which  may  assist  in  the  diagnosis. 

Gummatous  ulcers  are  usually  multiple  and  bilateral,  and  are  always 
upon  the  upper  surface  of  the  tongue ;  cancerous  ulcers  are  usually 
single,  and  may  occupy  its  under  surface.  The  ulcerative  process  of 
gummata  destroys  the  tumor;  carcinomata  present  an  ulcerating  tumor, 
the  induration  of  which  extends  with  the  eroding  process.  The  floor  of 
a  gummatous  ulcer  is  sometimes  sloughy  and  is  slightly  vascular  ;  that 
of  a  cancerous  ulcer  bleeds  readily,  and  at  an  advanced  stage  secretes  an 
ichorous  pus.  Zeissl  gives  diagnostic  importance  to  the  fact  that 
"  sebum-like  plugs "  may  be  pressed  from  the  mucous  membrane  in 
epithelioma  of  the  tongue. 

Interference  with  the  functions  of  the  tongue  is  much  less  in  gum- 
mata than  in  cancer.     Ganglionic  enlargement  is  rare  in  syphilitic  lesions 


620  SYPHILITIC  AFFECTIONS  OF  THE  TONGUE,   ETC. 

of  the  tongue,  with  the  exception  of  the  chancre,  while  in  cancer  it 
always  occurs. 

Confirmatory  evidence  may  be  furnished  by  microscopic  examination 
of  the  tumor  and  by  the  effect  of  antisyphilitic  treatment,  which  in 
cancer  is  sometimes  evidently  harmful. 

The  diagnosis  between  syphilis  and  tuberculosis  of  the  tongue  is- 
sometimes  difficult,  especially  in  those  cases  where  the  two  diseases 
coexist,  and  in  rare  instances  where  tubercular  deposit  takes  place  in  the 
tongue  prior  to  the  development  of  pulmonary  symptoms. 

In  all  cases  of  hyperplastic  growth  on  or  in  the  tongue  the  suspicion 
of  syphilis  should  be  entertained,  and  a  tentative  active  medication 
should  be  instituted. 

Atrophy  of  the  Tongue. 

Cases  of  atrophy  and  hemiatrophy  of  the  tongue  in  old  syphilitics 
have  been  reported,  but  more  precise  knowledge  is  required  before  we 
can  assert  that  syphilis  is  the  essential  cause  of  these  affections. 

GUMMATOUS  INFILTRATION  INTO  THE  SOFT  PALATE. 

There  are  few  syphilitic  lesions  which  develop  so  insidiously  and 
produce  such  almost  irreparable  injury  as  gummatous  infiltration  of  the 
soft  palate. 

Early  symptoms  are  insignificant  or  entirely  wanting.  Possibly 
the  patient  notices  a  slight  uneasy  or  tickling  sensation  in  the  fauces, 
and  experiences  some  difficulty  in  deglutition,  which  he  attributes 
to  an  ordinary  cold;  he  may  even  find  when  attempting  to  swallow 
liquids  that  they  regurgitate  through  the  nostrils,  but  this  he  regards  as 
accidental.  Suddenly,  however,  and  without  further  warning,  he  is 
nearly  deprived  of  the  power  of  speech  and  deglutition.  His  voice  is 
transformed  to  an  almost  unintelligible  nasal  whisper,  and  upon  attempt- 
ing to  eat,  solids,  and  especially  liquids,  are  returned  through  the  nose. 

If  we  are  so  fortunate  as  to  observe  this  affection  in  its  earliest  stage, 
we  find  that  it  has  two  modes  of  commencing: 

First.  A  deposit  of  gummy  material  may  take  place  in  a  circum- 
scribed mass  within  the  substance  of  the  soft  palate  and  between  its 
buccal  and  nasal  surfaces.  This  mode  of  origin  is  the  one  usually 
described  by  authors.  The  deposit  then  appears  as  a  flattened  tumor, 
of  the  size  of  a  bean  or  almond,  encroaching  upon  the  cavity  of  the 
mouth.  It  is  at  first  hard  to  the  touch,  but  subsequently,  when  second- 
ary degeneration  has  taken  place,  soft  and  fluctuating. 

Second.  In  other  cases  the  infiltration  is  diffuse.  No  tumor  exists, 
but  the  velum  is  generally  thickened,  its  mucous  membrane  reddened, 


GUMMATOUS  INFILTRATION  INTO   THE  SOFT  PALATE.       621 

and  its  mobility  impaired,  as  is  evident  when  the  patient  attempts  to 
articulate  or  to  swallow. 

Rupture  of  the  abscess  or  ulceration  of  the  infiltration  tissues  may 
involve  both  mucous  surfaces  or  only  one;  in  the  latter  case  it  is  usually 
the  buccal :  a  cavity  with  sharply  cut  and  ulcerated  edges  is  then  visible 
in  the  soft  palate,  while  possibly  the  voice  and  the  power  of  swallowing 
remain  unimpaired.  The  destructive  process,  however,  may  proceed 
with  great  rapidity,  and  complete  perforation  may  soon  follow.  The 
perforation  may  be  limited  in  extent,  but  frequently  a  large  portion  or 
the  whole  of  the  velum  is  destroyed,  together  with  the  uvula  and  the 
pillars  of  the  fauces,  and  thus  an  immense  door  of  communication  is 
opened  between  the  mouth  and  nose.  It  is  thus  easy  to  account  for  the 
indistinct  and  nasal  voice — or  "duck's  voice,"  as  the  French  call  it — 
of  such  patients,  and  also  for  the  reflux  of  liquids  and  even  solids,  and 
yet  the  absence  of  pain  which  characterized  the  onset  of  the  disease  is 
still  a  remarkable  feature,  since  deglutition,  although  so  difficult,  is 
attended  with  a  merely  trifling  sensation  of  discomfort.  In  addition, 
there  is  often  dulness  of  hearing,  due,  doubtless,  to  oedema  of  the  tissues 
composing  the  walls  of  the  pharynx  and  surrounding  the  orifices  of  the 
Eustachian  tubes. 

In  time  amelioration  of  these  symptoms  occurs.  What  remains  of 
the  velum  recovers  in  a  measure  its  pliability  and  renews  its  function. 
Practice  also  assists  in  teaching  the  patient  how  to  avoid  regurgitation 
of  solids  and  even  fluids.  Some  improvement  also  takes  place  in  the 
voice,  and  this  may  be  greatly  increased  by  wearing  a  proper  plate  made 
of  hard  rubber  or  gold.     The  impairment  of  hearing  is  only  temporary. 

It  remains  to  speak  of  a  remarkable  sequel  of  this  affection — viz.,  the 
change  which  usually  takes  place  in  the  fauces  as  a  consequence  of  the 
process  of  repair.  Directly  after  the  lesion  has  occurred  the  remains 
of  the  soft  palate  are  dependent,  and  the  opening  communicating  between 
the  mouth  and  nares  is  very  large.  One  would  naturally  suppose  that 
this  condition  would  continue,  or  would  be  aggravated  at  a  subse- 
quent period  after  cicatrization  had  taken  place.  Strange  to  say,  such  is 
not  the  course  of  events.  The  dependent  remains  of  the  palate  become 
elevated,  the  ulcerated  edges  contract  adhesion  with  the  ulcerated  walls 
of  the  pharynx,  and  the  opening,  which  at  first  was  very  large, 
gradually  contracts,  until  finally  complete  atresia  is  the  result,  or,  more 
frequently,  a  diminutive  channel  of  communication  remains  between  the 
buccal  and  nasal  cavities,  less  in  diameter  than  the  normal  opening. 

Cases  not  infrequently  occur  in  which  the  surgeon  may  hesitate  to 
express  an  opinion  as  to  the  cause  of  ulceration  and  perforation  of  the 
soft  palate.  Two  causes  only  are  likely  to  produce  this  result:  syphilis 
and  tuberculosis,  and  the  former  far  more  frequently  than  the  latter. 


622  SYPHILITIC  AFFECTIONS  OF  THE  TONGUE,   ETC. 

If  the  patient  presenting  this  lesion  be  an  adult  who  has  enjoyed  at 
least  tolerable  health  until  the  present  attack,  there  can  be  little  doubt 
that  the  cause  is  syphilis,  no  matter  if  a  syphilitic  history  is  obscure 
or  even  denied.  Admitting  the  honesty  of  the  patient,  the  primary 
and  secondary  symptoms  may  have  been  overlooked  or  forgotten  and 
have  left  no  traces. 

Tertiary  lesions  often  appear  years  after  the  secondary  stage,  and 
when  least  expected.  Then,  too,  they  are  isolated,  without  concomitant 
symptoms  to  assist  the  diagnosis. 

The  diagnosis  rests  between  syphilis  and  tuberculosis,  with  the 
chances  in  favor  of  the  former.  The  history  of  the  patient  should  be 
minutely  inquired  into,  and  the  eyes,  the  nose,  and  the  teeth  should  be 
carefully  examined  to  determine  whether  they  were  ever  affected  with 
syphilis. 

In  all  cases  the  effect  of  medication  is  a  valuable  aid  to  diagnosis. 
Syphilitic  ulceration  usually  yields  to  full  doses  of  iodide  of  potassium 
and  mercury.  Tuberculous  ulceration  may  be  benefited  by  the  same 
remedies,  especially  if  combined  with  tonics,  but  no  such  marked  im- 
provement is  observed  within  a  few  days. 

THE    PHARYNX. 

Lesions  similar  to  those  occurring  in  the  mouth  are  met  with  in  the 
pharynx.  Erythema,  superficial  ulcers,  and  deep  ulcerations  resulting 
from  degeneration  of  gummatous  deposit  may  be  observed.  The  occur- 
rence of  mucous  patches  in  the  pharynx  has  been  noted  by  several  au- 
thorities, but  they  are  not  common.  Frequently  ulcers  extend  into  the 
pharynx  from  the  posterior  nares. 

The  symptoms  of  pharyngeal  syphilis  are  usually  insignificant, 
except  in  the  case  of  ulcers,  when  there  may  be  pain,  aggravated  in 
the  act  of  swallowing  and  especially  on  the  ingestion  of  acrid  or  irri- 
tating substances.  The  posterior  portion  of  the  lateral  walls  of  the 
pharynx  is  more  often  attacked  than  the  posterior  wall.  Gummy 
tumors  have  been  observed  on  the  vault  of  the  pharynx  and  on  the 
upper  part  of  its  posterior  wall.  After  destroying  the  mucous  mem- 
brane the  disease  may  invade  the  vertebrae  and  produce  necrosis  or 
inflammation  of  the  contents  of  the  vertebral  canal. 

Syphilitie  ulcerations  of  the  pharynx  are  of  special  interest  on 
account  of  the  traces  which  they  leave  in  the  form  of  cicatrices  or  of 
adhesions,  which  diminish  the  capacity  of  the  cavity  and  interfere 
with  its  functions.  The  cicatrices  seen  upon  the  pharyngeal  wall  are 
characteristic.  They  may  present  a  stellate  appearance  or  may  assume 
the  form  of  prominent  bands.  The  cicatricial  tissue  is  white  and 
glistening,  and  may  persist  indefinitely  or  gradually  contract. 


THE  LARYNX.  623 

In  rare  cases  the  entire  soft  palate  is  destroyed  by  ulceration ;  necro- 
sis of  the  hard  palate  occurs,  and  the  mouth,  the  nose,  and  the  pharynx 
are  converted  into  one  enormous  cavity.  In  milder  cases,  when  the 
ulcerative  process  is  limited  to  the  border  of  the  velum  and  pharyngeal 
wall,  adhesions  may  form,  which  divide  the  cavity  of  the  pharynx  into 
two  distinct  chambers,  one  communicating  with  the  posterior  nares  and 
the  other  with  the  mouth.  There  may  be  a  very  narrow  passage  be- 
tween these  two  cavities,  or  they  may  be  completely  shut  off  from  each 
other,  respiration  being  carried  on  exclusively  through  the  mouth. 

Diagnosis. — It  is  often  very  difficult  to  distinguish  between  the  deep 
ulcerations  of  syphilis  and  those  of  tuberculosis.  There  are  at  least  four 
points  to  be  considered  in  making  a  diagnosis.  In  syphilis  other  lesions 
are  usually  found.  Syphilitic  ulcerations  follow  the  formation  of  a 
gummatous  tumor;  in  but  few  cases,  however,  on  account  of  the  very 
slight  inconvenience  occasioned  by  even  extensive  lesions,  is  the  patient 
observed  before  complete  destruction  of  the  original  gummy  tumor. 
Specific  ulcers  usually  progress  more  rapidly  than  tubercular  ulcers,  and 
generally  they  yield  to  specific  treatment.  Some  observers  claim  that  the 
ulcers  themselves  present  distinctive  characteristics,  but  this  is  rarely 
the  case. 

AFFECTIONS  OF    THE  LARYNX. 

In  tertiary  syphilis  the  larynx  may  be  attacked  by  chronic  inflam- 
mation, by  deep  ulcerations,  and  by  gummy  tumors.  As  secondary 
results  of  these  processes  perichondritis  and  caries  and  necroses  may 
be  developed. 

Chronic   Inflammation. 

Chronic  inflammation  of  the  larynx  is  an  intermediate  lesion  ;  it  may 
follow  an  early  catarrh,  or  may  not  appear  until  three  or  four  years 
after  infection.  The  affection  is  very  persistent,  and  commonly  leads  to 
thickening  or  hypertro'phy  of  the  mucous  membrane.  The  thickening  of 
the  cords  may  be  so  great  as  to  require  operative  interference  for  the  relief 
of  the  dyspnoea.  A  remarkable  instance  of  this  condition  has  been  re- 
ported, in  which  tracheotomy  was  done  four  times  during  a  period  of  five 
years.  Associated  with  this  condition  chronic  ulcers  are  almost  always 
found.  These  ulcers  have  ragged  and  thickened  edges  ;  frequently  vege- 
tations spring  from  them  which  may  reach  a  considerable  size,  even  to  the 
degree  of  producing  aphonia  and  of  impeding  respiration.  The  vocal 
cords,  which  are  thickened  and  rough,  are  very  often  the  seat  of  these 
ulcers.  The  ventricular  bands  may  be  so  swollen  as  to  overlap  the 
cords.  The  vegetations  which  may  grow  from  the  margins  of  an  ulcer 
or  from  other  portions  of  the  mucous  membrane  are  often  difficult  to 


624  SYPHILITIC  AFFECTIONS  OF  THE  TONGUE,  ETC. 

distinguish  from   simple  polypoid  growths.     Their  favorite  seat  is  at 
the  insertion  of  the  inferior  vocal  cords. 

Deep  Ulcerations. 

Deep  ulcerations  occurring  in  the  later  stages  of  syphilis  may  form 
by  extension  from  the  pharynx  or  by  degeneration  of  gummatous  de- 
posit. The  epiglottis  may  be  entirely  destroyed  by  the  ulcerative  proc- 
ess. Next  in  order  of  frequency  the  aryteno-epiglottic  ligaments  are 
attacked,  then  the  superior  vocal  cords,  and  more  rarely  the  true  cords. 
The  ulcerations,  especially  those  of  gummy  tumors,  are  very  irregular 
and  indurated.  Extensive  regions  may  be  destroyed  in  a  chronic  and 
insidious  manner,  irreparable  injury  being  done.  These  ulcerations 
can  hardly  be  confounded  with  those  of  tubercular  origin,  which  are 
smaller,  more  numerous,  and  more  superficial.  The  lardaceous  base 
and  the  general  appearance  of  the  lesions,  in  connection  with  cicatrices 
of  previous  ulceration,  suggest  their  specific  character.  They  are 
much  more  likely  to  be  mistaken  for. malignant  disease.  In  cancer  the 
tonsils  and  the  submaxillary  glands  are  at  an  early  period  the  seat  of 
infiltration.  Pain,  often  extreme,  is  distinctive  of  cancer,  while  the 
syphilitic  lesion  makes  much  slower  progress,  and  is  generally  painless 
until  the  tissues  have  been  extensively  destroyed.  In  most  cases  of 
syphilis,  moreover,  there  is  a  clear  history  of  infection,  and  traces  of 
former  lesions  may  be  discovered  in  the  mouth  or  pharynx  or  in  other 
regions  of  the  body. 

Gummy  Tumors. 

Gummy  tumors  of  the  larynx  are  much  more  common  than  has  been 
supposed.  The  lesion  is  often  single,  and  may  attain  a  very  large  size ; 
frequently  the  tumors  are  small  and  multiple,  and  may  be  limited  to  the 
mucous  and  submucous  tissues.  The  deposit  sometimes  undergoes  ab- 
sorption, but  more  frequently  it  degenerates,  forming  the  deep,  ragged 
ulcers  already  described,  which  may  involve  the  framework  of  the 
larynx  and  produce  permanent  deformity.  The  epiglottis  and  the 
arytenoids  are  most  often  involved,  but  any  of  the  laryngeal  cartilages 
may  suffer.  A  fatal  termination  may  ensue  in  the  course  of  these 
lesions  from  impediment  to  respiration,  due  to  the  size  of  the  tumor  or 
to  an  acute  oedema  of  the  larynx. 

Perichondritis. 

Perichondritis  is  generally  the  result  of  the  extension  of  an  inflam- 
matory or  ulcerative  process  from  the  mucous  and  submucous  tissues. 
The  cartilage  itself  may  be  involved.  Pain  of  a  marked  character  is 
a  common    symptom    of   this    lesion,    and    the    parts  are    sensitive  to 


THE  (ESOPHAGUS.  625 

external  pressure.  CEdema  of  the  soft  parts,  and  deformity  from  the 
structural  changes  in  the  affected  cartilage,  are  frequently  observed. 
The  epiglottis  and  the  arytenoid  cartilages  are  most  often  involved,  more 
rarely  the  cricoid.     They  may  be  entirely  destroyed. 

Caries. 

Caries,  or  true  necrosis,  in  cases  where  ossification  of  the  cartilage 
has  taken  place,  is  a  common  sequel  of  the  invasion  of  the  perichondrium 
by  inflammation  or  gummatous  ulceration.  It  is  always  a  very  late 
lesion,  and  frequently  induces  structural  changes  in  the  larynx  which 
cannot  be  remedied. 

THE  (ESOPHAGUS. 

The  oesophagus  is  very  rarely  attacked  in  the  tertiary  stage  of  syph- 
ilis, and  no  cases  are  on  record  in  which  it  was  the  seat  of  morbid  change 
in  the  secondary  stage. 

This  affection  begins  in  submucous  gummatous  infiltrations,  runs  a 
chronic  course,  and  leads  either  to  ulceration  or  absorption,  stricture 
inevitably  resulting  in  either  case.  If  the  case  is  seen  early,  active 
antisyphilitic  treatment  may  bring  about  resolution.  When  cicatricial 
stenosis  has  developed,  internal  treatment  will  be  of  no  use,  and  gradual 
dilatation,  if  possible,  should  be  tried.  In  extreme  cases  gastrostomy 
may  be  necessary. 

All  cases  of  stricture  of  the  oesophagus  arise  from  the  use  of  caustics, 
from  syphilis,  or  from  cancer. 

Traumatism  being  excluded,  the  diagnosis  rests  between  syphilis  and 
cancer. 

It  is  always  well  to  give  the  patient  a  thorough  tentative  course  of 
antisyphilitic  treatment.  It  is  well  to  remember  that  in  cases  of  syphilis 
of  the  oesophagus  epithelioma  is  liable  to  attack  the  specific  neoplasm  or 
its  sequelae. 

40 


CHAPTER   XL. 

SYPHILITIC   AFFECTIONS  OF  THE  TRACHEA,  BRONCHI, 
LUNGS,  AND   HEART. 

The  trachea,  bronchi,  lungs,  and  heart  may  be  the  seat  of  morbid 
changes  in  tertiary  syphilis.  The  trachea  alone  may  be  attacked ;  in 
some  patients  the  bronchi  are  involved ;  and  in  rare  cases  the  trachea, 
bronchi,  and  lungs  are  affected. 

These  affections  are  not  common,  and  we  are  not  to-day  in  possession 
of  sufficient  knowledge  to  allow  us  to  give  a  full  description  of  the 
clinical  history. 

Undoubtedly  some  cases  of  late  syphilitic  changes  in  these  parts  are 
diagnosticated  as  of  cancerous  origin,  and  in  many  their  syphilitic  nature 
is  only  ascertained  after  death. 

TRACHEA. 

The  lesions  in  tertiary  syphilis  of  the  trachea  are  gummatous  infil- 
tration and  dense  connective-tissue  proliferation.  As  a  result  of  these 
conditions  ulceration,  cicatrization,  and  stenosis  follow. 

The  most  prominent  symptoms  of  tracheal  stenosis  are — 1.  Dyspnoea, 
most  marked  during  inspiration,  and  especially  so  on  any  exertion  of 
the  patient.  This,  though  a  most  prominent  symptom,  may  occasionally 
be  absent,  though  the  obstruction  to  the  entrance  of  air  into  the  lungs 
may  be  very  great.  2.  A  hoarse,  weak,  or  croupy  voice,  even  if  the 
larynx  be  free  from  disease,  due  to  the  weak  air-current.  3.  Swelling 
of  the  jugulars  with  every  expiration,  due  to  the  abnormally  increased 
pressure  in  the  large  veins  within  the  thorax  during  expiration.  4. 
Slight  downward  movement  of  the  larynx  with  every  inspiration. 
This  movement  is  much  more  considerable  in  stenosis  of  the  larynx. 
5.  The  patient  breathes  easier  with  his  chin  depressed,  as  this  causes 
relaxation  and  dilatation  of  the  trachea.  In  laryngeal  stenosis,  on  the 
other  hand,  the  head  is  thrown  back  to  facilitate  the  breathing.  6. 
Retraction  of  the  lower  part  of  chest  with  every  inspiration.  7.  Loud 
inspiratory  stridor,  heard  best  over  the  sternum,  occasionally  accom- 
panied by  a  thrill  to  be  distinctly  felt  over  the  place  of  constriction. 
Auscultation  of  the  lungs  reveals  weak  breathing  and  loud  rhonchi, 
unless  there  be  some  lung  complication.  It  often  happens  that  the 
stricture  is  at  the  bifurcation  of  the  trachea,  and  extends  to  one  bronchus 
rather  than  to  both.     In  such  cases  we  have  the  characteristic  symptoms 

626 


THE  LUNGS.  627 

of  stricture  of  a  bronchus  (diminished  fremitus,  diminished  breathing, 
and  more  marked  inspiratory  retraction  of  the  ribs)  on  that  side.  In 
spite  of  these  definite  symptoms,  the  diagnosis  between  syphilitic 
stricture  of,  and  pressure  on,  the  trachea  is  sometimes  a  matter  of 
great  difficulty. 

BRONCHI. 

The  bronchi  are  similarly,  and  often  synchronously,  affected  by  the 
same  processes  which  attack  the  trachea.  There  are  many  more  or  less 
satisfactorily  reported  cases  of  late  syphilitic  disease  of  the  bronchi,  in 
all  of  which  stricture  is  the  prominent  feature. 

THE  LUNGS. 

Our  knowledge  of  the  pathological  anatomy  of  syphilitic  processes 
in  the  lungs  is  far  in  advance  of  that  of  its  symptomatology  and  clinical 
history.  The  truth  is,  that  we  have  not  yet  such  criteria  as  will  enable 
us  to  distinguish  sharply  in  the  living  subject  the  differences  between 
pulmonary  tuberculosis  and  syphilitic  infiltration  into  the  lungs.  Many 
mild  cases  of  localized  lung  disease  in  syphilitics  are  seen  which  get 
well  under  specific  treatment,  and  from  these  very  important  cases  we 
can  derive  no  anatomico-pathological  facts  which  will  show  us  just  what 
has  taken  place.  Then,  again,  in  many  cases  of  syphilitic  infection  the 
resulting  lung  trouble  is  complicated  by  essential  tubercular  lesions,  and 
this  symbiosis  makes  our  clinical  studies  uncertain  or  of  no  value. 

The  morbid  processes  of  syphilis  in  the  lungs  occur  in  the  form  of 
indurations  and  gummata.  Syphilitic  sclerosis  differs  from  tuberculous 
induration  of  the  lung  in  many  ways.  It  is  met  with,  as  a  rule,  in 
the  lower  or  middle  lobes  rather  than  at  the  apices,  and  in  the  form 
of  bands  and  fibrous  tracts  which  are  not  welded  together  into  a  com- 
pact mass,  but  may  enclose  islets  of  lung-tissue,  generally  more  or  less 
emphysematous.  The  fibrous  tissue  is  not  pigmented.  The  bronchi 
in  relation  with  these  indurations  are  often  flattened,  and  the  alveoli 
are  filled  with  exudative  fluid  containing  leucocytes  and  desquamated 
endothelial  cells.  The  pleura  is  often  thickened  and  adherent  about 
such  diseased  areas,  and  the  surface  of  the  lung  is  puckered  and  fur- 
rowed in  much  the  same  manner  as  the  surface  of  a  cirrhosed  liver. 
Syphilis  and  tubercle  may  be  combined  in  the  same  organ,  but  the 
appearance  of  the  sclerosed  tissue  is  distinct  in  each.  Cavities  and 
the  presence  of  fresh  tubercle  in  other  parts  will  aid  the  diagnosis. 
It  is  probable  that  many  cases  of  chronic  tuberculous  disease  have 
been  classed  in  literature  as  syphilitic.  Chronic  pneumonia  gives  a 
firm,  compact,  indurated  mass,  soft  and  glossy  to  the  feel,  and  not  puck- 
ered   on  the  surface.     Leprosy  of  the  lung  is  very  rarely  seen,    and 


628  SYPHILITIC  AFFECTIONS  OF  THE   TRACHEA,   ETC. 

the  characteristic  bacilli  would  serve  to  distinguish  it.  Gumma  of  the 
'lung  is  met  with  rather  more  frequently  than  syphilitic  induration, 
but  is  still  very  uncommon,  and  no  case  should  be  accepted  as  such 
without  absolute  proof.  Fatty  degeneration  takes  place  in  the  centre 
of  the  mass,  but  the  remains  of  alveolar  walls  and  flattened  epithelium 
can  often  be  recognized.  The  parts  around  may  be  thickened  by  pro- 
liferation of  lymphoid  cells  and  congestion,  and  around  the  whole 
mass,  which  is  indicated  under  the  term  "  gumma,"  there  is  always  a 
zone  of  indurated  tissue  more  or  less  firm  and  vascular.  The  fatty 
degeneration  of  the  centres  of  the  masses  may  lead  to  liquefaction,  and 
the  evacuation  of  the  fluid  thus  produced  causes  considerable  irritation 
of  bronchi.  Cicatrices  are  often  found  in  the  neighborhood  of  the 
gummata,  and  a  dry  pleurisy  is  usually  set  up,  which  results  in  dense 
adhesions.  Syphilis  never  causes  a  purely  serous  exudation  in  the 
pleura.  The  diagnosis  by  physical  signs  is  exceedingly  difficult,  and  the 
symptoms  are  apt  to  be  very  misleading.  Cough,  dyspnoea,  haemoptysis, 
and  mucopurulent  sputum  may  all  be  present,  but  the  absence  of  the 
bacilli  from  the  latter  will  form  an  important  element  in  the  diagnosis. 
Wasting,  as  a  rule,  only  occurs  when  the  liver  or  spleen  is  attacked  by 
the  disease,  and  it  may  thus  happen  that  wasting  will  be  progressive 
while  the  condition  of  the  lung  is  improving.  The  latter  tends  to  become 
stationary  after  a  while,  and  if  other  organs  are  not  affected  the  prog- 
nosis is  good.  The  suspicion  of  syphilis  should  always  attach  to  lesions 
beginning  in  the  lower  parts  of  the  lung,  and  slowly  progressing  without 
the  production  of  fever. 

AFFECTIONS  OF  THE  HEART. 

In  late  syphilis  the  heart  may  be  attacked  by  a  chronic  inflammation 
which  produces  a  sclerosing  fibrous  tissue,  and  it  may  be  the  seat  of 
gummata.  The  endocardium,  the  myocardium,  and  the  pericardium 
may  be  attacked. 

Endocarditis  usually  coexists  with  myocarditis.  The  walls  of  the 
heart  are  more  commonly  attacked  than  the  valves.  The  most  frequent 
location  of  endocarditis  is  in  the  left  ventricle,  at  the  apex  or  at  the  base 
of  the  heart  near  the  opening  of  the  aorta.  The  vegetative  or  verrucous 
form  is  much  less  common  than  the  fibrous  or  sclerotic.  Gummy  endo- 
carditis is  usually  combined  with  the  fibrous  form  of  syphilitic  myo- 
carditis and  pericarditis.  Its  clinical  symptoms  are  indefinite  and  little 
known.  Very  often  it  runs  its  course  without  apparent  symptoms. 
The  prognosis  is  unfavorable. 

Syphilitic  endocarditis  is  always  circumscribed,  and  rarely  occurs 
prior  to  the  second  year  after  infection.  The  fibrous  form  generally 
attacks  the  left  ventricle,  especially  at  the  apex,  the  anterior  wall,  and 


SYPHILITIC  AFFECTIONS   OF  THE  HEART  629 

the  septum  ventriculorum.  Its  origin  is  found  in  the  interfibrillar  con- 
nective tissue.  The  gummy  form  is  generally  associated  with  the 
fibrous,  and  affects  all  parts  of  the  organ  and  all  the  layers  of  its  wall. 
The  tumors  may  attain  the  size  of  a  hen's  egg  or  a  billiard-ball.  As 
lon^  as  the  destruction  of  muscular  substance  is  inconsiderable  or  com- 
pensated  by  hypertrophy  of  the  intact  tissue,  and  as  long  as  the  neuro- 
muscular apparatus  of  the  heart  is  unaffected,  the  myocarditis  occasions 
no  considerable  functional  disturbance. 

Syphilitic  pericarditis  is  rarely  primary,  but  usually  follows  myocar- 
ditis, and  therefore  involves  especially  the  visceral  layer.  But  the 
entire  pericardium  may  be  implicated.  The  chronic  or  fibrous  form 
leads  to  the  formation  of  a  compact,  coarse-fibred  tissue,  to  contraction, 
deformation  of  the  contiguous  surface  of  the  heart,  and  constriction  of 
the  great  vessels. 

Gummata  of  the  pericardium  rarely  occurs  except  as  the  result  of 
the  extension  of  myocarditis.  In  several  cases  it  has  been  noted  that 
the  process  began  in  the  aorta  and  extended  to  the  heart. 

The  symptomatology  of  syphilis  of  the  heart  shows  a  wide  range. 
It  includes  headache,  dizziness,  flashes  of  light,  loss  of  strength,  palpi- 
tation, dyspnoea,  feverishness,  sore  throat.  In  some  cases  there  were 
symptoms  of  angina  pectoris,  and  neuralgic  pains  like  those  of  aneurysm. 

Treatment. — If  the  nature  of  the  heart  lesion  is  recognized  suf- 
ficiently early,  much  benefit  may  follow  energetic  antisyphilitic  treat- 
ment. When  uninfluenced  by  medication  syphilis  of  the  heart  leads 
to  kidney  disease,  marasmus,  and  pulmonary  infarction.  It  is  not 
uncommon  to  find  the  coexistence  of  other  specific  visceral  lesions  with 
those  of  the  heart. 


CHAPTER  XLI. 

TERTIARY  AFFECTIONS  OF  THE  VISCERA. 

THE  LIVER. 

The  liver  is  more  frequently  attacked  by  syphilis  than  any  other 
abdominal  organ. 

In  tertiary  syphilis  of  the  liver  the  following  marked  conditions  may 
be  produced  :  (1)  amyloid  degeneration,  which  results  from  cachexia ; 
(2)  perihepatitis,  usually  with  decided  thickening  of  the  capsule,  leading 
to  adhesions  with  surrounding  parts ;  (3)  hepatitis,  in  which  there  is 
considerable  increase  in  the  connective  tissue,  followed  by  shrinking  and 
the  formation  of  cicatrices.  Of  hepatitis  there  are  two  forms — the  dif- 
fuse and  the  gummatous. 

The  symptoms  are  usually  so  mild  that  the  patient  has  no  suspicion 
that  his  liver  is  attacked  until  considerable  time  has  elapsed. 

The  liver  may  be  somewhat  enlarged,  and  is  frequently  irregular, 
and  on  its  surface  there  may  be  nodular  protuberances  of  the  size  of  a 
walnut  or  egg,  between  which  are  deep  sulci. 

Pain,  either  localized  or  diffused,  in  the  hepatic  region  is  the  most 
common  symptom.  It  may  be  sharp  and  severe  or  dull  and  persistent. 
It  is  made  worse  by  pressure  upon  the  organ.  This  symptom  generally 
ceases  in  a  gradual  manner. 

In  cases  of  perihepatitis  pain  is  sometimes  very  severe,  and  when  the 
process  is  recent  a  friction-sound  may  be  heard.  In  these  cases  the 
peritoneum  is  involved  by  the  extension  of  the  morbid  process.  As  a 
result  of  pressure  upon  the  portal  vein  ascites  may  occur.  The  spleen 
may  also  become  affected,  and  in  some  cases  there  is  hemorrhage  from 
the  stomach.  Albuminuria  is  a  very  common  complication.  Patients 
thus  affected  have  a  sickly,  earthy  look,  with  perhaps  some  bronzing  of 
the  skin.  In  some  cases  there  is  present  a  condition  of  marasmus 
accompanied  with  persistent  jaundice. 

The  diagnosis  of  liver-syphilis  should  be  based  on  the  history  of  the 
case,  on  its  symptoms,  and  on  concomitant  visceral  lesions.  From 
cancer  it  is  distinguished  by  the  synchronous  albuminuria  and  splenic 
enlargement,  by  the  very  great  irregularity  of  surface  produced  by  the 
protuberances,  and  by  its  slow  stationary  condition  during  a  long  period 
of  time.  In  cirrhosis  there  is  usually  no  history  of  syphilis,  but  one 
of  alcoholism    is,  as  a  rule,  readily  obtained. 

630 


THE  SPLEEN.  631 

The  prognosis  of  syphilis  of  the  liver  is  not  good,  but  relief  may 
result  from  treatment  if  begun  sufficiently  early. 

Syphilis  of  the  liver  occurs  more  frequently  in  men  than  in  women, 
and  appears  from  two  to  twenty  years  after  the  onset  of  the  infection. 
Peiser,  as  the  result  of  the  study  of  34  cases  of  liver-syphilis  (21  men, 
13  women),  in  which  the  date  of  infection  and  of  the  onset  of  the  vis- 
ceral disease  was  clearly  made  out  in  15,  found  that  it  began  as  follows  : 
At  2J  months  in  1  case  ;  2  years  in  1  ;  3  to  4  years  in  4 ;  6  to  7  years 
in  3;  12  years  in  1  ;  14  years  in  1  ;  18  years  in  1 ;  20  years  in  1; 
23  years  in  1 ;  25  years  in  1.  Structural  changes  in  the  liver  are  most 
commonly  found  in  patients  between  twenty  and  fifty  years  of  age. 

Cases  of  the  precocious  development  of  hepatitis  and  perihepatitis 
in  the  secondary  stage  of  syphilis  have  quite  rarely  been  observed. 

It  has  been  claimed  that  syphilis  may  cause  acute  yellow  atrophy 
of  the  liver. 

THE  SPLEEN. 

The  spleen  may  be  the  seat  of  structural  change  in  the  late  period 
of  syphilis. 

The  late  syphilitic  processes  in  the  spleen  consist  of  an  interstitial 
and  a  gummatous  infiltration. 

In  interstitial  inflammation  the  process  begins  around  the  blood- 
vessels, and  a  diffuse  connective  tissue  which  presses  on  the  pulp  is  pro- 
duced. In  this  condition  the  organ  may  be  much  diminished  in  size. 
The  connective-tissue  bands  are  paler  than  the  normal  tissue,  from 
which  they  do  not  project  at  all,  but  merge  diffusely  into  the  surround- 
ing spleen-tissue,  contain  but  little  blood  and  few  cells,  and  in  the  centre 
consist  of  a  finely  granular  material  in  which  a  few  cells  and  nuclei  are 
imbedded. 

Gummata. — Gummata  vary  in  size  from  that  of  a  millet-seed  to  that 
of  a  walnut,  and  may  be  few  in  number  or  very  numerous.  Their 
number  is  usually  greater  when  their  size  is  small.  In  some  cases  the 
spleen  itself  is  enlarged.  The  tumors  are  usually  found  near  the  tra- 
becular and  deeply  seated,  or  at  the  periphery  of  the  organ  ;  in  the  latter 
case  the  capsule  is  thickened.  Recent  tumors  have  a  reddish-gray  color, 
and  are  more  dense  and  tough  than  the  normal  spleen-tissue  ;  when  old 
they  are  dry  and  of  a  yellowish-gray  color.  When  young  they  are  less 
clearly  defined  than  at  a  later  period,  when  they  may  become  distinctly 
encapsulated.  The  vessels  and  the  structure  of  the  organ  in  the 
neighborhood  of  the  tumors  are  more  or  less  destroyed.  Cicatricial 
contraction,  especially  in  the  capsule,  subsequently  occurs.  The  spleen 
has  several  times  been  found  adherent  to  the  diaphragm  in  consequence 
of  peritonitis  from  irritation  by  gummy  tumors. 


632  TERTIARY  AFFECTIONS   OF  THE   VISCERA. 

We  know  little  of  the  symptomatology  of  this  affection.  Enlarge- 
ment of  the  spleen  is  sometimes  demonstrable,  and  in  some  cases,  when 
the  tumors  are  superficial,  inflammation  of  the  capsule  and  localized 
peritonitis  occur. 

In  the  cases  hitherto  observed  the  lesion  has  generally  been  accom- 
panied by  similar  affections  of  other  viscera,  and  the  patients  have  suf- 
fered from  cachexia  or  marasmus. 

When  the  liver  or  the  spleen  is  attacked  by  syphilis  the  morbid  pro- 
cess may  extend  to  and  involve  the  peritoneum  more  or  less  extensively. 
This  membrane  may  also  become  involved  when  the  various  other 
viscera  are  the  seat  of  syphilitic  infiltration. 

THE  STOMACH. 

There  are  no  symptoms  which  are  pathognomonic  of  syphilitic  lesions 
of  the  stomach.  Syphilis  of  the  stomach  is  of  very  rare  occurrence, 
and  it  is  generally  recognized  after  death  by  means  of  the  microscope. 

Several  cases  have  been  reported  of  patients  who  suffered  from 
gastric  pains  and  vomiting  and  wdio  died  of  marasmus,  in  whose 
stomachs  on  post-mortem  examination  round  ulcers  were  found.  In 
most  of  these  cases  the  history  is  incomplete,  and  though  the  micro- 
scopic findings  of  the  morbid  tissues  pointed  to  syphilis  in  some 
instances,  the  patients  died  of  tuberculosis. 

INTESTINES. 

Our  knowledge  of  the  effect  of  syphilis  on  the  intestines  is  based  on 
post-mortem  studies,  and  it  is  at  best  very  meagre.  A  number  of  cases 
are  on  record  in  which  it  is  claimed  that  certain  ulcers  in  the  ilium  and 
large  intestine  were  due  to  syphilis;  but  their  details  are  so  unsatis- 
factory that  they  fail  to  convince  one  that  these  lesions  were  caused  by 
syphilis. 

THE  RECTUM. 

Syphilitic  affections  of  the  rectum  are  to-day  not  very  well  under- 
stood, but  it  is  possible  to  describe  them  in  a  tolerably  clear  manner. 

Syphilis  attacks  the  rectum  in  three  distinct  forms  :  first,  early  or 
rather  late  in  the  course  of  the  disease  by  the  extension  of  indurating 
oedema,  which  may  accompany  infiltrating  or  ulcerating  vulvar  or  anal 
lesions,  and  which  tends  to  the  production  of  more  or  less  complete 
rings  of  connective  tissue ;  second,  by  the  formation  of  true  gummatous 
infiltration ;  and,  third,  by  the  development  of  a  form  of  inflammation 
with  the  production  of  new  connective  tissue,  in  which  congestion  and 
exudative  products  are  absent.  This  third  form  is  a  chronic  productive 
or  cellular  inflammation  of  slow  invasion  and  of  persistent  nature. 


THE  RECTUM.  633 

Indurating  oedema  complicates  early  and  late  syphilitic  infiltrations 
and  ulcerations  which  are  seated  in  the  vulva  or  vagina  and  near  and 
in  the  anus.  The  indurating  process  then  extends  to  and  surrounds 
the  anus,  either  between  the  two  sphincters  or  about  one,  two,  or  three 
inches  above  the  internal  one.  The  walls  of  the  rectum  become  thick- 
ened, less  supple  and  extensible,  than  they  are  normally,  and  ulcerated, 
and  if  proper  treatment  is  not  adopted  in  the  course  of  several  months 
or  a  year  or  two  a  tough  and  diffuse  stricture  is  formed.  This  form  of 
rectal  stricture  is  usually  found  in  syphilitic  women  in  the  secondary 
or  early  tertiary  stage.  It  is  generally  the  result  of  neglect  of  treat- 
ment of  their  lesions.  These  structures  are  seated  two  or  three  inches 
within  the  anal  orifice. 

In  some  cases  the  ulcerations  in  these  cases  present  points  of  resem- 
blance to  chancroids,  and  for  this  reason  some  authors  speak  of  chan- 
croidal stricture  of  the  rectum.  Chronic  chancroids  may  produce 
stenosis  of  this  tube,  but  it  will  generally  be  found  that  their  bearers 
also  suffered  from  syphilis. 

This  form  of  rectal  stricture,  if  seen  and  treated  early  by  local  and 
systemic  medication,  is  curable.  Its  prognosis  is  better  in  proportion 
as  the  infection  is  recent. 

The  second  form  of  syphilis  of  the  rectum  may  or  may  not  result 
in  stricture.  The  essential  features  of  this  affection  observed  by  me 
will  give  a  clear  idea  of  its  nature  and  course.  It  was  that  of  a  man 
thirty-three  years  old,  who,  after  a  prolonged  attack  of  diarrhoea,  suf- 
fered from  obstinate  constipation  and  experienced  an  uneasy  sensation 
in  the  rectum,  particularly  at  the  anus,  when  at  stool  and  at  various 
times  during  the  day.  About  two  inches  above  the  sphincter,  on  the 
posterior  wall  of  the  rectum,  a  thickened  patch  of  mucous  membrane 
two  inches  long  and  one  and  a  half  wide,  with  sharp  and  abrupt  mar- 
gins, co.uld  be  seen.  The  surface  of  this  lesion  was  somewhat  papil- 
lomatous, and  its  structure  was  firm.  Under  active  local  and  general 
treatment  resolution  slowly  took  place,  and  a  firm  cicatrix  which  did 
not  materially  contract  the  tube  was  left. 

Several  similar  cases  have  been  reported  in  which  the  rectal  wall 
was  found  to  be  the  seat  of  gummatous  infiltration  which  on  being 
absorbed  has  left  the  tube  more  or  less  stenosed.  In  some  cases  the 
full  circumference  of  the  tube  has  been  found  to  be  the  seat  of  this 
morbid  process.  Local  and  general  treatment  is  quite  efficient  in  this 
class  of  cases. 

I  have  seen  several  cases  in  which  syphilitic  infiltration  of  the  pos- 
terior vaginal  wall  increased  in  depth  and  attacked  the  rectum,  which 
as  a  result  became  stenosed. 

The  third  form  of  syphilitic  disease  of  the  rectum  is  that  of  annular 


634  TERTIARY  AFFECTIONS  OF  THE   VISCERA. 

fibroid  stricture,  and  it  is  not  due  to  an  essential  syphilitic  process,  but 
it  belongs  in  the  catagory  of  parasyphilitic  affections,  in  which  this 
disease  shows  a  tendency  to  productive  and  cellular  inflammation.  This 
occurs  very  frequently  in  the  genitals  of  young,  and  particularly  of  old, 
syphilitic  women  long  after  the  activity  of  the  diathesis  has  ceased.  In 
some  cases  the  external  genitals  are  the  seat  of  the  hyperplasia,  and  in 
others  the  vaginal  walls  are  attacked. 

Either  synchronously  with  the  vulvar  or  vaginal  affection,  or  in  an 
uncomplicated  state,  this  affection  attacks  the  rectal  wall  and  runs 
around  it  in  ringed  form.  As  has  already  been  stated,  there  is  no 
hyperemia,  and  there  are  no  exudative  products  :  there  is  simply  this 
chronic  productive  inflammation,  which  goes  slowly  and  persistently  on, 
and  inevitably  leads  to  the  formation  of  a  dense,  unyielding  ring  of 
fibrous  tissue,  which  may  in  the  end  thoroughly  occlude  the  gut.  Why 
syphilis  should  thus  lead  to  the  cellular  inflammation  localized  to  a 
segment  of  the  rectum,  from  three  to  six  inches  above  the  anus,  we  do 
not  know.  Nor  do  we  know  whether  any  traumatic  conditions  tend 
thus  to  localize  this  stenosing  process.  We  do  know,  however,  that  in 
some  syphilitic  women  a  periproctitis  differing  in  no  particular  from 
that  found  in  uninfected  women,  occurs,  and  that  it  entails  long  suffer- 
ing, and  may  lead  to  death. 

LESIONS  OF  THE  KIDNEY,  LATE  GLYCOSURIA,  AND 
DIABETES  INSIPIDUS. 

Kidney  disease  in  late  syphilis  is  of  rather  uncommon,  but  not  of 
rare,  occurrence.  In  9000  autopsies  Wagner  found  63  cases  of  syphilis 
of  the  kidneys ;  of  these,  8  were  cases  of  acute  Bright's  disease,  4  of 
chronic,  7  of  granular  kidney,  6  of  atrophy  of  one  kidney,  35  of  amy- 
loid degeneration,  and  3  of  syphiloma  or  gummata.  Bamberger  found 
49  cases  of  syphilis  of  the  kidney  in  2340  cases  of  acute  and  chronic 
Bright's  disease.  Wagner  follows  Beer's  division  of  the  pathological 
changes  of  the  kidneys  in  syphilis.  These  are — 1.  Small  circum- 
scribed nodular  formations  (gummatous  tumors)  in  otherwise  normal 
•or  differently  diseased  kidneys.  2.  Simple  interstitial  hyperplasia,  mostly 
irregular,  with  the  formation  of  cicatrices  in  otherwise  normal  kidneys. 
3.  Diffuse  cellular  hyperplasia  of  the  interstitial  tissues,  mostly  with 
degeneration  of  the  vessels  and  atrophy  of  the  new  formation,  as  well 
as  peculiar  parenchymatous  changes.  These  latter  were  particularly 
small  fatty  deposits,  lardaceous  degeneration  being  common  in  this 
form.  4.  Purely  parenchymatous  changes.  According  to  Wagner  and 
Beer,  only  the  first  and  third  forms  are  absolutely  characteristic  of 
syphilis. 

There  are  no  pathognomonic  signs  or  symptoms  of  tertiary  syphilis 


DIABETES  INSIPIDUS.  635 

of  the  kidneys.     The  symptoms  are  emaciation  and  various  forms  of 
dropsy,  together  with  the  presence  of  albumin  in  the  urine. 

Late  Glycosuria  and  Syphilis. 

The  question  of  the  relation  between  syphilis  and  glycosuria,  or 
diabetes,  has  of  late  been  much  studied,  but  still  there  is  much  to  be 
learned. 

Patients  suffering  from  diabetes,  who  later  on  contract  syphilis, 
usually  present  a  severe  order  of  primary  and  secondary  manifestations, 
due  to  the  hybrid  morbid  condition.  In  many  instances  the  initial 
lesion  in  these  subjects  is  more  exuberant  and  shows  decided  tendency 
to  ulceration.  With  the  onset  of  syphilis,  which  is  usually  very  rapid, 
diabetes  seems  to  induce  a  condition  of  deep  cachexia,  and  as  a  result 
the  course  of  the  disease  is  more  severe  and  less  amenable  to  treatment. 
In  these  cases  mercury  should  be  used  very  guardedly.  In  general, 
the  mixed  treatment  works  well  toward  the  end  of  the  first  year. 
Several  writers  have  stated  that  sugar  seems  to  leave  the  urine  more 
rapidly  in  syphilitic  than  in  other  patients.  Several  instances  are  known 
in  which  sugar  disappeared  at  the  breaking  out  of  specific  manifesta- 
tions, and  reappeared  on  the  cessation.  In  diabetes  and  syphilis  there 
is  frequently  observed  a  fermentation  of  the  sugar  in  the  mouth,  which 
produces  severe  and  rebellious  ulcerative  lesions.  Though  this  morbid 
combination  tends  to  induce  great  deterioration  of  nutrition,  the  con- 
soling fact  remains  that  in  some  syphilitic  sugar  disappears  more  per- 
manently than  in  those  uninfected. 

That  syphilis,  therefore,  may  in  some  mysterious  manner  cause  dia- 
betes there  can  no  longer  be  any  doubt.  So  many  cases  have  been  re- 
ported in  which  no  other  pathogenic  cause  than  syphilis  could  be 
ascertained  that  the  conclusion  is  warranted  that  diabetes  may  result 
from  the  effects  of  that  far-reaching  infection,  either  by  its  disturbance  of 
the  liver  and  of  the  blood-making  function,  or  by  reason  of  some 
change  in  the  fourth  ventricle  or  in  its  vicinity. 

Diabetes  may  occur  within  the  first  few  months  of  infection  within 
one  or  several  weeks,  and  it  may  occur  in  the  tertiary  stage. 

Diabetes  Insipidus. 

In  the  course  of  syphilitic  disease  of  the  brain,  particularly  when 
seated  at  or  near  the  floor  of  the  fourth  ventricle,  diabetes  or  polyuria  is 
sometimes  observed.  It  has  no  distinguishing  characteristics,  and  its 
chief  symptoms  are  inordinate  thirst  and  the  discharge  of  large 
quantities  of  pale  urine  of  very  low  specific  gravity,  in  which  neither 
sugar  nor  albumin  is  found. 

A    number    of    interestingr    cases    are    to    be    found     in    literature. 


636  TERTIARY  AFFECTIONS   OF  THE   VISCERA. 

Lecorche  and  Talamon  have  reported  the  case  of  a  thirty-four-year 
syphilitic  man  who  had  been  infected  fourteen  years  before,  and  who 
for  six  years  had  passed  nine  to  ten  litres  of  urine  daily.  Under  treat- 
ment the  quantity  was  reduced  to  five  litres. 

Sourouktchy  has  reported  the  case  of  a  twenty-five-year-old  man 
who,  when  seven  months  syphilitic,  was  affected  with  great  thirst,  and 
passed  large  quantities  of  urine  free  from  sugar  and  albumin.  He  was 
promptly  cured  by  the  use  of  mercurial  inunctions  and  of  iodide  of 
potassium  internally.  The  reporter  of  the  case  thought  that  there  was 
a  syphilitic  affection  of  the  ependyma  in  the  floor  of  the  fourth  ventricle. 

In  a  case  reported  by  Buttersack,  in  which  the  woman  suffered  from 
vertigo,  neuralgic  pains,  and  pains  in  the  head,  and  who  voided  a  large 
amount  of  characteristic  urine,  on  post-mortem  examination  chronic 
descending  leptomeningitis,  with  implication  of  the  trigeminal  and 
spinal  nerves,  was  found. 

The  suprarenal  capsules  have  in  a  few  cases  been  found  to  be  the 
seat  of  connective-tissue  increase  and  gummatous  infiltration.  A  case 
is  reported  in  which  during  life  the  morbid  conditions  of  Addison's 
disease  were  observed,  and  at  the  autopsy  what  appeared  to  be  gumma- 
tous degeneration  of  the  suprarenal  capsules  was  found. 


CHAPTER   XLII. 

SYPHILITIC   AFFECTIONS  OF  THE  MUSCLES,  TENDINOUS 
SHEATHS,  APONEUROSES,  AND  BURSJ3. 

MYOSITIS. 

Myositis  is  sometimes  found  in  secondary  syphilis,  but  generally  in 
the  tertiary  stage.  It  occurs  in  three  principal  forms  :  first,  the  irrita- 
tive or  hypersemic  ;  second,  the  chronic  infiltrative ;  and,  third,  in  the 
form  of  gummatous  nodules. 

Irritative  myositis  is  usually  seen  to  coexist  with  the  early  manifes- 
tations, particularly  of  the  lower  joints  and  tendons,  and  it  is  attended 
with  rheumatoid  pain,  soreness,  and  perhaps  impairment  of  function. 
The  myalgias  produced  by  the  early  irritative  syphilitic  process  are,  as 
a  rule,  ephemeral  and  readily  yield  to  proper  treatment.  In  this  form 
of  myositis  no  permanent  structural  change  is  produced. 

Chronic  myositis  tends  to  more  or  less  permanent  contraction  of  the 
member  or  parts  on  or  in  which  the  muscle  is  situated.  It  occurs  in  two 
forms — the  localized  and  the  diffuse. 

According  to  Virchow,  this  lesion  is  analogous  to  that  produced  by 
rheumatic  inflammation.  "  In  the  interspaces  between  the  muscular 
fasciculi  a  connective  tissue  is  developed,  which  hardens  and  results  in 
atrophy,  and  finally  in  the  destruction  of  the  primitive  muscular  fibrils." 
We  thus  find  at  the  outset  the  presence  of  abnormal  nuclei,  cells,  and 
fibres  in  the  cellular  tissue,  and  afterward  a  secondary  degeneration  of 
this  new  formation,  resulting  in  atrophy  of  the  normal  elements,  con- 
traction of  the  muscle  itself,  and  in  some  instances  calcareous  and  bony 
deposits.  This  lesion  usually  escapes  observation  until  the  contraction 
of  the  muscle,  interfering  with  motion  or  producing  flexion  of  the  limb, 
attracts  attention. 

As  a  rule  this  affection  causes  no  pain,  but  exceptionally  a  dull, 
aching  sensation  is  complained  of. 

One  or  more  muscles  may  be  attacked.  Those  most  frequently 
affected  are  the  flexors  of  the  upper  extremity,  and  especially  the  biceps. 

The  contraction  comes  on  insidiously,  and  the  first  symptom  noticed 
by  the  patient  is  an  inability  to  extend  the  limb.  On  examining  the 
affected  muscle  no  change  is  perceptible  by  palpation  either  in  its  size  or 
texture  ;  its  power  of  contraction  is  normal  ;  and  there  is  simply  a  dimi- 
nution in  length,  as  shown  by  its  tension  when  the  limb  is  forcibly  ex- 
tended.    The  tendon  of  insertion  of  the  biceps  is  always  prominent  and 

637 


638  SYPHILITIC  AFFECTIONS  OF  THE  MUSCLES,   ETC. 

tense,  and  the  muscle  itself  appears  to  be  in  a  state  of  partial  contrac- 
tion. Somewhat  rarely  the  masseter  muscles,  one  or  both,  may  be 
attacked. 

GUMMATOUS  TUMORS. 

These  tumors  begin  in  round-cell  infiltrations  around  the  vessels  of 
the  perimysium.  They  grow  slowly  and  usually  without  pain,  and 
reach  various  sizes,  and  sometimes,  as  in  Koehler's  case,  they  involve  a 
large  mass  of  muscles.  In  this  case  the  tumor  extended  from  the  left 
hypochondrium  to  the  inguinal  fold,  and  from  the  linea  alba  to  the 
axillary  line.  In  JSTetter's  case  the  tumor  was  seated  in  the  sartorius 
muscle,  was  subaponeurotic,  and  was  five  inches  long  by  four  inches 
wide.  These  tumors  are  of  various  shapes,  globular,  fusiform,  flat,  or 
irregular,  according  to  the  nature  of  the  parts  in  which  they  are  seated. 
When  superficial  they  become  adherent  to  the  aponeurosis,  which 
becomes  inflamed  and  hypertrophied.  Being  frequently  developed  near 
the  ends  of  the  muscles,  the  tendons  are  sometimes  secondarily  involved. 

They  are  most  easily  detected  when  the  muscle  is  relaxed,  and  their 
independence  of  the  subjacent  bone  can  then  be  best  established.  They 
excite  little  or  no  pain,  unless  the  muscle  be  put  upon  the  stretch,  and 
their  chief  inconvenience  is  due  to  their  interference  with  motion.  They 
sometimes  produce  contraction  of  the  muscles,  but  this  is  not  a  neces- 
sary result. 

These  gummatous  tumors  of  the  muscles  may,  in  exceptional  cases, 
undergo  softening,  break  down,  and  form  deep  ulcers." 

They  are  very  often  accompanied  by  other  syphilitic  manifestations, 
such  as  nodes,  exostoses,  tubercles  of  the  cellular  tissues,  or  ulcerations 
of  the  fauces. 

Their  prognosis  is  good,  particularly  if  they  are  treated  early. 

The  diffuse  and  the  localized  myosites  are  rather  rarely  found  in 
combination. 

AFFECTIONS  OF  THE  TENDINOUS  SHEATHS  AND  OF  THE 
TENDONS  AND  APONEUROSES. 

These  structures  are  sometimes  attacked  in  early  and  in  late  syphilis. 
In  the  early  stage,  and  in  the  second  and  third  years  of  syphilis,  these 
parts  may  be  the  seat  of  an  irritative  process  which  may  give  rise  to 
effusion  or  to  the  development  of  fibrous  tissue.  In  tertiary  syphilis 
they  sometimes  become  infiltrated  by  gummatous  deposits. 

We  sometimes  see  swellings  which  occur  on  the  backs  of  the  hands, 
and  which  follow  the  course  of  the  tendons,  but  never  extend  beyond 
the  dorsal  ligament ;  they  are  of  triangular  shape,  with  their  base 
toward  the  fingers.     They  are  due  to  effusion  and  yield  a  sensation  of 


THE  BURSM.  639 

fluctuation  ;  they  cause  little,  if  any,  pain,  unless  of  unusually  large 
size,  when  the  skin  over  them  may  be  inflamed  and  painful.  They 
occur  in  the  early  years  of  syphilis  and  are  developed  rapidly. 

The  tendons  of  the  wrist,  ankle,  foot — in  fact,  any  tendon — may  be 
thus  attacked.  The  lesion  is  a  hyperemia  of  the  sheath  attended  by 
serous  effusion.  The  shape  of  the  resulting  tumors  varies  according  to 
the  conformation  of  the  parts. 

They  are  firm  and  elastic  and  sometimes  fluctuate.  The  overlying 
skin  is  frequently  reddened.  They  form  rapidly,  and  are  often  attended 
with  pain.  Fournier  believes  that  many  of  the  early  pains  of  syphilis 
are  due  to  hyperemia  of  the  sheaths  of  the  tendons,  and  especially  that 
the  pain  sometimes  present  in  the  bend  of  the  elbow,  intensified  by  firm 
pressure,  is  due  to  inflammation  of  the  tendon  of  the  biceps. 

Tendons  may,  in  rare  cases,  be  the  seat  of  gummy  infiltrations,  which 
exist  in  the  form  of  small  subcutaneous  tumors,  usually  unattended  by 
spontaneous  pain.  After  remaining  indolent  for  a  long  time  they  may 
break  down  and  form  troublesome  ulcers. 

The  aponeuroses  may  be  the  seat  of  localized  or  diffuse  fibroid  infil- 
tration. 

AFFECTIONS  OF  THE  BURSJE. 

The  bursas  are  rather  infrequently  attacked  by  irritative  and  hyper- 
plastic processes  in  secondary  and  tertiary  syphilis. 

In  the  secondary  period,  sometimes  coincidently  with  the  onset  of 
general  manifestations,  one  or  more  bursas  are  affected.  As  a  result,  we 
find  decided  swellings — not,  however,  very  sharply  definable — under 
the  skin,  which  may  or  may  not  be  hyperasmic.  These  early  bursal 
swellings  on  palpation  yield  a  fluctuation  or  a  doughy  sensation.  They 
are  sometimes  rather  sensitive,  but  not,  as  a  rule,  painful.  They  dis- 
appear promptly  under  specific  treatment,  provided  the  parts  on  which 
they  are  seated  are  put  at  rest  and  are  not  subjected  to  pressure.  In 
the  first  five  years  of  syphilis  hyperplasia  of  bursas  somewhat  rarely 
occurs  in  the  form  of  sharply  circumscribed,  rather  firm  tumors,  which 
run  an  indolent  and  painless  course  until  affected  by  local  and  general 
treatment. 

In  the  tertiary  stage  affections  of  the  bursas  are  not  infrequent.  The 
bursas  over  the  patellas  are  most  commonly  attacked.  The  lesion  is  a 
gummous  infiltration  with  formation  of  connective  tissue.  It  begins 
insidiously  and  without  pain  ;  the  patient's  attention  is  first  attracted  by  a 
hard  movable  lump  beneath  the  skin.  It  varies  in  size  and  shape  in  dif- 
ferent bursas.  Over  the  knee-joint  we  have  found  tumors  as  large  as  a 
walnut  or  as  an  egg.  (See  Fig.  153.)  The  tumor  may  remain  indolent  for 
a  long  time,  giving  very  slight  discomfort.     In  some  cases  it  is  excessively 


640 


SYPHILITIC  AFFECTIONS  OF  THE  MUSCLES,   ETC. 


hard,  in  others  it  is  quite  elastic.  Sometimes  the  parts  seem  to  be  infil- 
trated with  fluid.  If  not  treated,  and  particularly  if  subjected  to  irrita- 
tion, the  tumor  grows  and  becomes  adherent  to  the  overlying  skin. 
Inflammatory  symptoms  appear  and  the  integument  over  the  bursse 
ulcerates.  The  inflamed  and  infiltrated  bursa  may  sometimes  be  seen 
at  the  base  of  the  ulcer.     Under  such  circumstances  the  course  of  the 


Fig.  153. 


Tertiary  syphilis  of  the  hursse  patella. 

lesion  is  very  tedious.  In  other  cases,  even  of  very  large  tumors,  treat- 
ment causes  their  absorption  within  two  or  three  months.  The  lesion 
may  be  unilateral,  but  frequently  attacks  both  patellar  bursas.  In  many 
cases  traumatism  is  an  important  exciting  cause  ;  in  others  the  bursse 
are  secondarily  involved  by  the  extension  of  gummatous  infiltration 
from  adjacent  parts.     Relapses  are  quite  frequent. 

This  affection  occurs  most  commonly  in  women.    Gummatous  bursitis 
appears  both  early  and  quite  late  in  tertiary  syphilis. 


CHAPTER   XLIII. 

SYPHILITIC  AFFECTIONS  OF    THE   BONES,  JOINTS,   FINGERS, 

AND   TOES. 

AFFECTIONS  OF  THE  BONES. 

The  bones  are  sometimes  attacked  in  the  secondary  period  of 
syphilis,  but  osseous  affections  are  more  common  in  the  tertiary  stage. 
While  the  secondary  lesions  of  the  bones  are  usually  cured  very  readily, 
those  of  the  tertiary  period  are  very  persistent  and  prone  to  undergo 
degenerative  changes. 

The  pathological  changes  in  bones  are  osteoperiostitis,  rarefying 
osteitis,  and  intense  rarefying  osteomyelitis  or  gummatous  osteoperi- 
ostitis. From  these  morbid  conditions  formative  osteitis,  or  eburnation, 
exostoses,  or  nodes,  necroses,  and  sequestra  result. 

Syphilitic  osteoperiostitis  is  very  similar  to  the  simple  form.  It  is 
limited  to  the  superficial  layers  of  the  bone  and  to  the  periosteum,  and 
chiefly  attacks  the  long  bones  and  the  cranial  bones. 

The  affection  begins  in  the  connective  tissue  and  around  the  vessels 
of  the  Haversian  canals.  Thus  the  parts  are  infiltrated  with  numerous 
round  cells.  Besides  the  cell-infiltrations  into  the  periosteum,  the  mem- 
brane is  also  cedematous.  These  conditions  are  found  in  the  early 
stages  of  osteoperiostitis.  In  the  bones  the  Haversian  canals  become 
enlarged  and  filled  with  marrow,  which  is  either  red  or  embryonal  or 
gray  and  gelatinous.  In  the  stage  of  cedematous  infiltration  osteoperi- 
ostitis may  undergo  resolution  from  the  effect  of  specific  treatment. 

When  the  process  becomes  old  the  newly  formed  cells  act  as  osteo- 
blasts and  new  bone-tissue  is  formed.  As  a  result,  we  find  swellings 
of  the  bones,  which  are  called  exostoses  and  periostoses.  This  hyper- 
plastic process  is  called  formative  osteitis  or  eburnation. 

In  ramifying  osteitis  the  subperiosteal  tissue  and  the  osseous  marrow 
contain  small  round  cells  and  transuded  red  corpuscles.  When  this 
exudation  of  cells  is  intense,  the  bone-tissue  becomes  eroded  and  de- 
stroyed upon  the  internal  surface  of  the  Haversian  canals.  The  osseous 
lamellae  are  destroyed,  and  replaced  by  inflamed  marrow.  Under  treat- 
ment this  process  may  be  stayed  and  cured. 

Gummatous  osteomyelitis  and  osteoperiostitis  are  more  advanced 
conditions  than  those  just  described  :  the  subperiosteal  embryonal  tissue 
and  the  medullary  tissue  are  much  more  abundant,  and  these  structures 
become  arranged  like  that  of  gummata. 

41  641 


642  SYPHILITIC  AFFECTIONS  OF  THE  BONES,  ETC. 

Osteoperiostitis. 

The  bones  most  liable  to  be  attacked  by  osteoperiostitis  are  those 
which  are  the  most  superficial,  as  the  tibia,  ulna,  clavicle,  sternum,  and 
cranium,  but  no  portion  of  the  skeleton  can  be  said  to  be  exempt.  The 
external  manifestation  of  this  affection  consists  in  ill-defined,  doughy 
tumors  of  variable  size,  shading  off  gradually  into  the  surrounding 
tissues,  adherent  to  the  osseous  structure  beneath,  but  independent  of 
the  overlying  integument,  usually  very  sensitive  to  pressure,  the  seat, 
at  certain  hours  in   the   twenty- four,  of  severe  pain,  and  bearing  the 

Fig.  154. 


x 


Osteoperiostitis  of  tibia. 


common  name  of  nodes.  (See  Fig.  154.)  A  striking  particularity  of 
the  pains  produced  by  nodes  is  their  marked  nocturnal  character.  They 
are  generally  absent  or  are  scarcely  felt  during  the  day,  but  return  at 


EXOSTOSIS.  643 

night  with  great  severity  after  the  patient  retires  to  bed,  and  only  abate 
toward  morning. 

In  the  majority  of  cases  of  nodes  the  infiltration  is  absorbed  under 
appropriate  treatment  and  the  tumor  undergoes  resolution.  In  other 
cases  the  inflammation  is  more  acute ;  the  skin  becomes  adherent  to  the 
tumor,  is  reddened  and  thinned ;  degeneration  and  softening  take  place, 
and  an  opening  is  formed ;  the  ulcer  shows  little  or  no  tendency  to  ex- 
tend, but  a  superficial  portion  of  the  bone  to  a  limited  extent  usually 
becomes  necrosed  and  comes  away,  and  an  adherent  cicatrix  is  the  final 
result. 

Exostoses. 

When  eburnation  of  the  bony  tissue  is  developed  the  result  is  an 
exostosis.  Such  new  growths  are  often,  for  a  time  at  least,  movable 
upon  the  bone  beneath,  and  are  then  called  epiphysary  exostoses.  In 
this  form  they  are  due  rather  to  periostitis  than  ostitis  ;  they  are  gener- 
ally of  small  size,  sometimes  thin  and  flat,  sometimes  hemispherical  or 
pedunculated,  and  at  times  annular.  They  acquire  greater  consistency 
with  time,  and  finally  present  an  eburnated  texture.  Arrived  at  this 
point,  resolution  is  no  longer  possible ;  the  tumor  remains  stationary, 
and  treatment  has  no  other  effect  than  to  quiet  the  osteocopic  pains. 
If  resolution  be  attained  at  an  early  period,  their  surface,  which  before 
was  smooth,  becomes  irregular,  indicating  partial  absorption.  Some- 
times this  absorption  continues  after  the  whole  of  the  tumor  has  dis- 
appeared, so  that  local  atrophy  of  the  bone  succeeds  the  exostosis.  In 
other  instances  syphilitic  exostosis  is  not  preceded  by  periostitis,  but  is 
the  result  of  ostitis  terminating  in  hypertrophy  of  the  normal  bony 
tissue,  in  which  case  it  is  denominated  parenchymatous  exostosis. 

An  exostosis  situated  externally  rarely  occasions  sufficient  incon- 
venience or  deformity  to  necessitate  its  removal  by  an  operation  unless 
under  peculiar  circumstances. 

Exostosis  may  spring  from  the  internal  surface  of  the  cranial  bones, 
and  give  rise  to  symptoms  of  the  most  serious  character,  as  convulsions 
and  the  various  forms  of  paralysis.  The  frontal  bone  is  by  far  the 
most  frequently  affected  in  this  manner. 

Syphilitic  exostosis  of  the  vertebrae,  either  external  or  within  the 
spinal  canal,  is  rare. 

Syphilitic  exostoses  may  generally  be  distinguished  from  similar 
growths  due  to  other  causes  by  the  nocturnal  pains  attending  them,  by 
their  usually  occupying  the  continuity  of  the  more  superficial  bones,  by 
their  hemispherical  form,  and  by  the  fact  that  they  are  rarely  multiple 
or  symmetrical  on  opposite  sides  of  the  body. 


644 


SYPHILITIC  AFFECTIONS  OF  THE  BONES,  ETC. 


Gummatous  Osteoperiostitis  and  Osteomyelitis. 

The  bones  most  commonly  attacked  by  these  processes  are  the  long 
bones,  the  cranial  bones,  and  the  bones  of  the  fingers  and  toes. 

When  the  bones  of  the  skull  are  aifected,  one  or  more  nodes  are  de- 
veloped. As  a  rule,  in  the  late  secondary  and  in  the  early  tertiary 
stages  we  find  several  or,  in   rare  cases,  as  many  as  twenty,  nodes  on 

Fig.  155. 


Gummatous  osteoperiostitis :  multiple  nodes  of  the  skull-bones. 

the  cranial  bones,  whereas  at  late  periods  there  may  be  but  one  or  two. 
These  multiple  cranial  nodes  usually  make  their  appearance  by  crops 
of  one  or  more.  Single  nodes  run  a  slow  course,  and  one  may  be  fol- 
lowed by  its  successor  after  the  lapse  of  months  or  years. 

In  Fig.  155  multiple  gummatous  nodes  are  well  shown. 

The  bones  of  the  face,  particularly  the  malar  bones,  may  be  attacked 


GUMMATOUS  OSTEOPERIOSTITIS  AND   OSTEOMYELITIS.       645 

by  gummatous  osteoperiostitis,  and  iu  the  course  of  the  affection  mild  or 
severe  neuralgic  pain  may  be  felt.      (See  Fig.  156.) 

The  superior  maxillary  bone  is  not  infrequently  attacked.  The  first 
symptoms  are  local  swelling  and  pain,  and  later  the  cheeks  and  the 
tissues  around  the  eyes  become  red  and  oedematous.     Very  often  the 

Fig.  156. 


Showing  a  large  cranial  node,  necrosis  of  skull,  cicatrix  of  skin,  and  fall  of  nose. 

whole  bone  is  destroyed.  In  some  cases  the  periosteum  is  left  intact 
and  a  new  bone  forms. 

The  inferior  maxillary  may  be  the  seat  of  nodes  on  its  external  sur- 
face or  lower  border. 

The  clavicle,  scapula,  and  ribs  are  not  uncommonly  the  seat  of  nodes 
of  varying  sizes.  Gummata  of  the  scapula  may  be  mistaken  for  cold 
abscess  and  osteosarcoma,  and  it  is  always  well  to  think  of  syphilis  in  all 
cases  of  swellings  of  this  bone. 

A  goodly  number  of  cases  of  gummatous  osteoperiostitis  of  the  verte- 
brae have  been  published.     In  these  cases  pain  caused  by  pressure  on 


646  SYPHILITIC  AFFECTIONS  OF  THE  BONES,  ETC. 

the  nerves  was  complained  of,  and  in  some  cases  there  was  paralysis  of 
the  upper  or  lower  extremities. 

The  bodies  of  the  vertebrae  are  much  more  frequently  attacked  than 
are  the  arches.  In  a  number  of  cases  of  syphilis  of  the  vertebrae  strik- 
ingly beneficial  results  have  followed  the  use  of  the  mixed  treatment. 

Fragility  of  Bones. 

As  the  result  of  local  inflammation  and  cell-infiltration  in  casts  of 
rarefying  and  gummatous  osteoperiostitis  the  structure  of  bones  some- 
times becomes  fragile,  and  they  are  fractured  by  muscular  contraction 
or  mild  or  severe  traumatism.  It  is  probable  that  non-union  is  either 
due  to  a  depraved  condition  or  to  the  fact  that  the  newly  formed 
embryonal  tissues  do  not  produce  an  ossifying  callus,  but,  on  the  con- 
trary, caseous,  fatty,  and  sclerotic  tissues,  which  tend  to  produce  false 
joints.  In  these  cases  local  and  general  medication  and  good  hygiene 
are  very  essential. 

AFFECTIONS  OF  THE  JOINTS. 

The  joints  are  frequently  affected  by  syphilis  in  both  the  secondary 
and  tertiary  stages.  In  some  instances  the  morbid  process  begins  in  the 
joint-structures,  and  in  others  inflammation  of  the  articular  ends  of  the 
bones  and  of  the  large  tendons  inserted  near  the  joint  involves  the  latter 
secondarily. 

Synovitis  of  the  Late  Stage. 

The  synovitis  which  occurs  late  in  the  secondary  and  during  the  ter- 
tiary stage  is  also  markedly  subacute.  It  is  attended  with  the  same  symp- 
toms, and  is  mainly  distinguishable  from  that  of  the  earlier  period  by 
appreciable  lesions  of  the  joint-structures.  The  attention  of  the  patient 
is  called  to  the  affection  by  slight  pain  and  impairment  of  motion,  and 
the  joint  is  then  found  somewhat  enlarged.  The  effusion  into  its  cavity 
takes  place  slowly  and  perhaps  intermittingly,  so  that  in  many  cases 
several  months  elapse  before  the  joint  is  very  decidedly  enlarged.  When 
the  affection  is  fully  developed  we  find  evidence  of  intra-articular  effusion 
and  general  thickening  of  the  fibrous  coverings  and  of  the  synovial 
membrane. 

This  affection  may  remain  in  an  indolent  condition  for  years  without 
undergoing  further  changes.  There  is  little  tendency  to  complete 
ankylosis,  though  quite  frequently  there  is  more  or  less  erosion  of  the 
articular  cartilages,  as  shown  by  the  crepitation  on  motion.  We  seldom 
find  sinuses  near  the  joints,  and  the  stationary  character  of  the  affection 
is  in  marked  contrast  to  the  tendency  to  degeneration  which  is  such  a 


DACTYLITIS  SYPHILITICA.  647 

prominent  feature  of  the  tuberculous  affections  of  these  parts.  The 
knee-joint  is  the  one  most  commonly  attacked. 

Late  syphilitic  synovitis  may  be  complicated  by  tuberculosis,  and  the 
mixed  condition  then  produced  is  very  rebellious  to  treatment,  which  is 
sometimes  signally  efficacious  in  the  true  syphilitic  affection. 

In  many  cases  a  history  of  syphilis  points  to  the  nature  of  the  affec- 
tion. Then  in  tuberculosis  this  morbid  process  usually  exists  elsewhere, 
particularly  in  the  lungs.  In  the  mixed  form  of  synovitis  it  is  often 
impossible  to  make  a  sharp  diagnosis. 

In  some  cases  in  which  there  is  a  syphilitic  affection  of  the  tendons 
inserted  near  a  joint  there  is  a  coincident  effusion  into  the  cavity  of  the 
latter.  This  occurs  slowly  and  painlessly,  and  disappears  on  the  sub- 
sidence of  the  disease  of  the  tendon. 

The  prognosis  of  this  affection  is  rather  more  serious  than  that  of 
the  earlier  form.  If  it  is  submitted  to  treatment  early,  it  is  in  general 
curable  ;  but  if  it  is  neglected,  permanent  thickening  occurs,  and  con- 
sequently more  or  less  impairment  of  motion. 

The  constitutional  treatment  consists  in  the  administration  of  the 
iodide  of  potassium  and  of  mercury  in  full  doses.  The  joint  should  be 
enveloped  in  lint  thickly  spread  with  mercurial  ointment,  over  which 
cotton-wool  is  placed  and  the  whole  retained  in  place  by  means  of  a 
firm  muslin  bandage. 

AFFECTIONS  OF  THE  FINGERS. 

Dactylitis  Syphilitica. 

The  affection  is  caused  both  by  acquired  and  hereditary  syphilis,  and 
of  it  there  are  two  varieties  :  first,  that  in  which  the  morbid  process 
begins  in  the  bones  and  periosteum,  subsequently  implicating  the  joints  ; 
and  secondly,  in  which  the  morbid  deposit  occurs  in  the  subcutaneous 
connective  tissue  of  the  fingers  or  toes,  and  which  may  extend  to  the 
joints. 

These  varieties  are  constantly  found,  and  their  adoption  will  simplify 
description.  In  the  first  form  the  lesion  develops  slowly  and  first 
attracts  the  patient's  attention  by  the  slight  enlargement  of  one  or  more 
fingers  or  toes.  The  swelling  gradually  increases  and  the  member 
becomes  hard  and  firm.  The  skin  becomes  somewhat  stretched  and 
perhaps  hypersemic.  Wh  n  the  toes  are  affected  their  whole  length  is 
generally  included  ;  but  when  a  finger  is  attacked  the  lesion  may  be 
quite  sharply  limited  to  one  phalanx,  almost  invariably  the  proximal 
one,  or  the  adjacent  phalanx  may  be  involved  to  a  less  degree.  (See 
Fig.  157.)  The  distal  phalanges  and  the  metacarpal  bones  may  also  be 
attacked  (see  Fig.  158),  or,  finally,  the  whole  finger  may  be  affected. 


648 


SYPHILITIC  AFFECTIONS  OF  THE  BONES,  ETC. 


Fig.  157  shows  the  infiltration  into  the  first  and  second  phalanges  of 
the  left  hand. 


Fig.  157. 


Dactylitis  syphilitica. 


These  swellings  are  usually  developed  slowly  and  painlessly,  but  in 
some  cases  a  dull  aching  pain  is  present. 

Within  a  few  weeks  after  the  development  of  the  affection  symptoms 
of  joint-implication  may  appear.     At  first  flexion  of  the  joints  is  im- 


Fig.  158. 


Dactylitis  syphilitica. 


paired  by  the  swelling.  In  the  course  of  one  or  two  months,  if  no 
treatment  is  instituted,  the  joints  become  flaccid  and  unnaturally  mobile. 
Sometimes  in  this  variety  of  dactylitis  there  is  slight  hydrarthrosis,  and 


DACTYLITIS  SYPHILITICA.  649 

often    crepitation    in    the    metacarpophalangeal   joint    or   between    the 
articular  surfaces  of  two  phalanges. 

The  first  form  of  dactylitis  is  sharply  limited  to  the  bone,  and  is  due 
either  to  specific  periostitis  or  osteomyelitis.  The  affection  may  progress 
rapidly,  slowly,  or  with  intermissions.  The  earlier  after  the  infection 
the  lesion  occurs  the  more  acute  is  its  course. 

Fig.  159. 


Dactylitis  of  the  second  phalanx  with  gummatous  deposit  in  the  skin,  which  has  ulcerated. 

The  proximal  phalanx  is  most  frequently,  the  distal  phalanx  least 
frequently,  involved. 

The  fingers  are  attacked  more  commonly  than  the  toes ;  in  a  few 
cases  they  have  been  involved  simultaneously.  More  than  one  phalanx 
of  the  same  finger  may  be  affected  as  well  as  several  fingers,  either  uni- 
laterally or  symmetrically.  In  the  latter  case  swelling  of  one  or  more 
toes  is  likely  to  occur  at  the  same  time. 

The  metacarpal,  and  less  frequently  the  metatarsal,  bones  may  be- 
come swollen  coincidently  with  dactylitis,  or  they  alone  may  be  affected. 
In  some  cases  an  effusion  into  the  joint-cavity  takes  place  slowly  and 
without  pain. 

These  bony  swellings  may  remain  in  an  indolent  condition  for  a  long 
time,  and  finally  the  gummy  deposit  may  be  absorbed,  or  it  may  soften 
and  be  discharged  through  a  sinus.  The  shaft  of  the  bone  may  resume 
its  normal  size,  or  it  may  be  rendered  much  thinner  and  lighter.  Some- 
times it  is  shortened,  and  in  other  cases  again  it  is  slightly  longer  than 
normal.  The  bone  may  be  left  in  a  condition  of  eburnation,  being 
decidedly  thickened. 

The  process  of  involution  may  be  slow  or  quite  rapid,  and  seems  to 
be  in  proportion  to  the  rapidity  of  the  development  of  the  lesion.  In 
most  cases  the  deformity  is  not  very  marked  ;  in  some  cases  of  necrosis 
a  less  fortunate  result  is  obtained  (Fig.  160).  The  illustration  shows 
deformity  and  shortening  of  the  index-finger  so  that  its  extremity 
scarcely  reaches  the  first  phalangeal  joint  of  the  middle  finger.  In 
this  case  the  greater  part  of  the  first  phalanx  and  the  distal  extremity 
of  the  metacarpal  bone  had    been  absorbed,  and   the  remnants  of  the 


650 


SYPHILITIC  AFFECTIONS  OF  THE  BONES,  ETC. 


two  bones  were  connected  by  fibrous  tissue.  In  a  similar  manner  the 
second  phalanx  of  the  ring  finger  had  been  shortened  to  about  one-fourth 
of  its  original  length.  After  the  process  of  absorption  is  complete  the 
contiguous  bones  are  always  united  by  a  ligamentous  band,  which  serves 
as  a  joint.  The  function  of  a  finger  is,  of  course,  greatly  impaired,  and 
excessive  deformity  may  result.  The  manner  in  which  the  soft  parts 
adapt  themselves  to  the  altered  condition  is  remarkable,  their  contrac- 
tion being  of  great  service  in  giving  solidity  to  the  false  joints. 

The  second  form  of  dactylitis  is  much  less  common  than  the  first 
variety.  The  essential  lesion  is  gummatous  infiltration  into  the  subcu- 
taneous connective  tissue  of  one  or  more  fingers.     Generally  the  new 

Fig.  160. 


~~"*»»»_3>!eSi 


Showing  shortening  of  the  index-finger  from  absorption  of  part  of  the  phalanx  and  of  the  meta- 
carpal bone. 


formation  involves  the  whole  length  of  the  finger,  but  in  some  cases 
only  a  portion  (usually  in  the  neighborhood  of  a  joint)  is  swollen. 
Fingers  or  toes  thus  attacked  are  much  larger  than  normal,  often  hard 
and  tense,  and  more  or  less  chronically  hyperremic. 

This  affection  may  run  a  slow,  indolent  course  and  end  in  resolution  ; 
or  degenerative  changes  may  attack  the  infiltration,  in  which  event  an 
abscess  is  formed  (see  Fig.  159). 

In  this  form  of  dactylitis,  when  the  process  is  very  chronic,  the 
joint-structures  may  be  attacked,  in  which  event  subsequent  deformity 
and  disability  are  observed. 

Diagnosis. — So  marked  are  the  features  of  the  bony  swelling  of 
dactylitis  syphilitica  "that  the  affection  is  readily  recognized.  The 
history  of  the  case  may  reveal  the  specific  origin  of  the  trouble,  or  the 
history  of  antecedent  and  the  presence  of  concomitant  syphilitic  lesions 


DACTYLITIS  SYPHILITICA.  651 

may  make  the  question  clear.  The  slowness  of  growth,  the  indolent 
course,  and  in  most  cases  the  good  effect  of  antisyphilitic  treatment  will 
point  to  the  syphilitic  origin  of  the  bony  tumors. 

The  subcutaneous  variety  in  its  early  stage  may  be  mistaken  for 
periouychia  ;  but  the  absence  of  acute  inflammatory  symptoms,  especially 
pain,  establishes  the  diagnosis.  Dactylitis  of  the  great  toe  might  be 
mistaken  for  gout  but  for  the  subacute  character  of  the  former. 

The  prognosis  depends  in  a  measure  upon  the  period  at  which  the 
lesion  is  recognized.  When  the  swelling  is  developed  quickly,  rapid 
involution  follows  energetic  treatment.  The  longer  the  swelling  has 
persisted  the  less  amenable  to  treatment  it  becomes. 

In  some  cases,  particularly  in  children,  the  syphilitic  process  is  com- 
plicated with  tubercular  infection,  in  which  event  antisyphilitic  treat- 
ment is  useless  and  degenerative  changes  are  prone  to  occur. 

The  treatment  is  that  of  late  syphilis,  a  combination  of  the  iodide 
of  potassium  with  a  mercurial ;  locally,  mercurial  ointment  or  plaster 
applied  with  pressure  is  beneficial. 


CHAPTER   XLIV. 

SYPHILITIC  AFFECTIONS  OF  THE  PENIS,  OS  UTERI,  UTERUS, 

AND  VAGINA. 

In  somewhat  rare  cases  a  diffuse  gummatous  infiltration  occurs  in 
the  submucous  connective  tissue  of  the  glans  penis,  either  in  a  localized 
or  general  form.  This  new  tissue  may  break  down,  and  as  a  result  we 
sometimes  see  deep  ulcers  which  are  indistinguishable  from  chancroids 
in  appearance.  In  exceptional  cases  more  or  less  of  the  glans  itself 
may  be  the  seat  of  gummatous  infiltration. 

It  is  necessary  also  to  remember  that  relapsing  indurations  occur 
early  and  late  in  syphilis,  and  that  they  are  found  in  the  glans,  prepuce, 
at  the  meatus,  and  in  the  urethra. 

NODES  IN  THE  CORPORA  CAVERNOSA. 

In  some  cases  nodules  varying  in  size  between  that  of  a  pea  and  a 
nutmeg  may  be  found  in  the  meshes  of  the  corpus  cavernosum.  These 
tumors  are  usually  round.  They  are  generally  sharply  defined,  have  a 
moderately  firm  consistence,  and  may  present  cartilaginous  hardness. 

These  lesions  develop  very  insidiously,  and  in  speaking  of  them 
patients  usually  say  they  knew  of  no  trouble  until  they  noticed  the  lump 
in  the  penis.  As  a  result  of  the  infiltration  the  penis  becomes  curved 
in  various  directions  when  erect — laterally,  upward,  and  backward  and 
downward.  If  these  swellings  of  the  cavernous  bodies  are  allowed  to 
become  chronic,  they  produce  much  structural  deformity  of  the  penis. 
They  rarely  soften  and  break  down.  They  are  promptly  influenced  for 
the  better  by  antisyphilitic  treatment. 

Infiltrations  of  the  size  of  a  pea  or  of  a  hazelnut  are  not  frequently 
found  in  the  corpus  spongiosum,  and  may  extend  to  the  parts  beyond. 
They  run  an  indolent  course  and  rarely  break  down,  but  become  sclerotic 
and  produce  intractable  urethral  strictures. 

EXULCERATIVE  HYPERTROPHY  OP  THE  UTERUS. 

This  affection  consists  in  a  total  or  partial  enlargement  and  harden- 
ing of  the  os,  which  appears  congested  and  is  more  or  less  superficially 
ulcerated ;  its  surface  is  granular  or  often  presents  a  varnished  aspect. 
The  hypertrophy  is  greatest  in  the  transverse  diameter.  The  parts  are 
indurated  and  resistant,  or  sometimes  doughy,  and  generally  are  not 

652 


AFFECTIONS  OF  THE   OVARIES,   ETC.  653 

sensitive  to  manipulation.  In  most  of  the  cases  there  were  no  symp- 
toms referable  to  the  utero-ovarian  system  ;  in  others  the  patients  com- 
plained merely  of  certain  unpleasant  sensations,  such  as  pain  in  the 
loins,  back,  and  thighs,  and  a  bearing-down  feeling.  The  secretion 
from  the  ulcer  is  scanty  and  mucopurulent,  and  is  infectious  like  the 
secretion  from  other  secondary  lesions.  The  affection  may  be  accom- 
panied by  various  displacements  of  the  womb. 

AFFECTIONS  OF  THE  OVARIES,  FALLOPIAN  TUBES, 
UTERUS,  AND  VAGINA. 

Syphilitic  affections  of  the  ovaries  are  rarely  met  with  ;  they  present 
a  close  analogy  to  syphilitic  affections  of  the  testicle,  and  are  either  dif- 
fuse or  circumscribed.  Lancereaux  has  only  met  with  the  diffuse  form 
after  it  had  arrived  at  the  stage  of  atrophy  ;  the  ovaries  were  of  the 
usual  size  or  smaller  than  natural,  fibrous  in  structure,  with  scattered 
cicatrices,  and  destitute  of  Graafian  vesicles,  although  the  patients  had 
not  yet  arrived  at  the  usual  age  for  the  cessation  of  the  menses. 

The  symptoms  of  these  affections  are  said  to  be  a  slight,  dull  pain 
in  the  region  of  the  ovaries,  possibly  at  the  outset  some  increase  in  the 
size  of  these  organs  perceptible  on  abdominal  and  vaginal  palpation,  a 
loss  of  sexual  passion,  and  sterility.  It  is  evident  that  these  signs, 
taken  in  connection  with  the  history  of  the  case,  can  only  furnish  a 
probability  of  the  nature  of  the  disease.  The  success  of  antisyphilitic 
treatment  may  be  of  diagnostic  import  (Lancereaux). 

No  instance  is  known  in  which  the  Fallopian  tubes  have  been 
affected  with  syphilis. 

Certain  cases  in  which  uterine  tumors  in  syphilitic  subjects  have 
yielded  to  the  internal  administration  of  iodide  of  potassium  and  mer- 
curials render  it  probable  that  this  organ  is  not  exempt  from  the  late 
manifestations  of  syphilis;  but  nothing  more  definite  is  known  upon  the 
subject,  since  post-mortem  investigation  has  been  wanting.  The  vagina 
is  in  rare  cases  the  seat  of  localized  gummatous  infiltration,  which  is 
usually  developed  on  the  posterior  wall.  This  infiltration  may  extend  to 
the  rectum  and  give  rise  to  stricture  of  that  tube.  The  breaking  down 
of  this  new  growth  sometimes  leads  to  the  development  of  rectovaginal 
fistula. 


CHAPTEE   XLV. 

SYPHILITIC  AFFECTIONS  OF  THE  EPIDIDYMIS  AND  TESTIS. 

Like  all  organs  and  structures  rich  in  connective  tissue,  the  testicle 
and  its  appendages  are  attacked  both  early  and  late  in  the  course  of 
syphilis. 

THE  EPIDIDYMIS. 

In  somewhat  rare  cases  the  epididymis  is  the  seat  of  an  irritative 
process  at  the  time  of  the  general  manifestations.  One  or  both  may  be 
slightly  enlarged,  sensitive,  and  mildly  painful.  This  ephemeral  con- 
dition promptly  yields  to  treatment.  It  may  occur  in  patients  who 
have  suffered  from  gonorrhoea  and  its  epididymitis,  and  in  those  who 
have  never  been  thus  affected. 

In  some  cases  syphilitic  epididymitis  begins  insidiously,  and  is  not 
recognized  until  "  a  lump "  is  felt  by  the  patient ;  in  others  a  slight 
uneasiness  attends  its  formation.  Upon  examination  we  find  a  round  or 
oval  tumor  of  the  size  of  a  pea  to  a  lima-bean  just  above  the  testis,  the 
scrotum  itself  being  unaffected.  It  usually  has  a  smooth  surface  and  is 
of  a  decidedly  firm  consistency.  It  may  be  seated  in  one  epididymis 
only,  but  usually  both  are  affected.  Such  tumors  remain  in  an  indo- 
lent condition  without  showing  any  tendency  to  degeneration,  and  they 
always  promptly  disappear  under  mercurial  treatment.  Other  portions 
of  the  epididymis  or  the  testicle  itself  are  commonly  not  attacked 
simultaneously. 

This  affection  is  usually  a  somewhat  precocious  manifestation  of 
syphilis,  occurring  in  most  cases  within  the  first  six  months,  and  some- 
times as  early  as  the  second  month,  or,  again,  as  late  as  the  fifth  year, 
after  infection.  It  is  more  commonly  unilateral  when  it  occurs  at  a 
late  period.  An  important  point  in  the  diagnosis  of  this  affection  is 
that,  as  a  rule,  it  attacks  the  globus  major,  whereas  in  gonorrheal 
epididymitis  the  globus  minor  is  most  commonly  involved  alone. 

Late  in  the  secondary  and  in  the  tertiary  stages  the  epididymis  may 
be  attacked.  The  resulting  affection  is  of  slow  and  usually  painless 
growth,  and,  as  a  rule,  patients  are  ignorant  of  the  presence  of  any 
testicular  trouble  until  they  discover  a  lump  on  the  organ.  The  epi- 
didymis, in  part  or  in  whole,  is  then  found  to  be  swollen  and  hard,  and 
perhaps  a  little  sensitive  on  pressure. 

No  sharply  drawn  description  can  be  given  of  the  condition  of  the 
654 


THE  EPIDIDYMIS.  655 

epididymis  when  the  seat  of  tertiary  syphilis.  This  appendage  may 
be  uniformly  and  evenly  swollen,  it  may  be  the  seat  of  bulbous  expan- 
sions, and  it  may  be  markedly  nodular.  In  uncomplicated  cases, 
particularly  if  seen  quite  early,  prompt  resolution  of  the  hyperplasia 
may  follow  active  internal  and  local  treatment.  When  seen  late,  treat- 
ment has  a  limited  effect,  for  the  reason  that  dense  fibrous  tissue  or 
caseated  gummatous  tissue  has  been  produced,  and  much  disorganiza- 
tion has  resulted.  In  general,  even  after  what  may  be  called  good 
results  have  been  produced,  more  or  less  firmness  and  rigidity  of  the 
parts  are  left. 

Diagnosis. — The  early  form  of  epididymitis  is  generally  easy  of 
recognition,  since  it  usually  coexists  with  or  rapidly  follows  general 
manifestations.  In  many  cases  a  clear  history  of  syphilis  is  readily 
obtained. 

In  the  later  syphilitic  epididymitis  it  is  often  very  difficult,  to  arrive 
at  a  satisfactory  diagnosis.  In  a  given  case  we  must  bear  in  mind  that 
an  antecedent  inflammation,  caused  by  gonorrhoea  or  some  other  in- 
fectious disease,  may  have  been  the  underlying  cause  of  the  swelling. 
In  cases  of  chronic  posterior  urethritis  it  is  not  uncommon  to  find  a 
chronic  fibroid  epididymitis,  which  may  develop  acutely  and  then  run 
a  chronic  and  painless  course,  or  it  may  begin  insidiously  in  a  sluggish 
manner,  or  there  may  be  exacerbations  of  acuity.  When  in  these  cases 
a  history  of  syphilis  is  also  obtainable,  it  is  often  impossible  to  deter- 
mine whether  that  diathesis  has  any  influence  upon  the  morbid  process. 

Chronic  epididymitis  may  result  from  trauma,  but  usually  a  clear 
history  may  be  obtained. 

In  some  cases  of  late  syphilitic  epididymitis  there  is  a  symbiosis 
with  tuberculosis,  and  it  is  utterly  impossible  to  make  a  sharply  drawn 
diagnosis.  The  physical  signs  are  sometimes  very  similar  and  even 
identical,  and  our  reliance  is  then  to  be  placed  on  the  results  which 
follow  active  local  and  general  antisyphilitic  treatment.  Syphilitic  con- 
ditions are  thereby  more  or  less  benefited,  while  in  tuberculosis  at  the 
best  only  a  moderate  improvement  may  follow  .the  use  of  the  iodide  of 
potassium. 

It  is  always  well  in  cases  of  chronic  epididymitis,  even  if  nodulation 
is  present,  not  to  jump  too  hastily  at  the  conclusion  that  tuberculosis  is 
the  cause,  which  now-a-days  is  so  frequently  done.  In  considering  these 
cases,  the  surgeon  should  bear  in  mind  chronic  posterior  urethritis, 
trauma,  antecedent  infectious  processes,  syphilis,  tuberculosis,  and  the 
tuberculo-syphilitic  symbiosis. 

In  some  cases  of  early  and  late  syphilitic  epididymitis  the  juxta-tes- 
ticular  part  of  the  vas  deferens  is  the  seat  of  irritative,  hyperplastic,  or 
gummatous  changes. 


656      SYPHILITIC  AFFECTIONS  OF  THE  EPIDIDYMIS  AND   TESTIS. 

THE  TESTIS. 

In  tertiary  syphilis  the  body  of  the  testis  and  the  tunica  vaginalis 
may  be  attacked  by  chronic  hyperplastic  processes  peculiar  to  that 
period.  In  general,  the  body  of  the  testis  is  alone  attacked,  and  excep- 
tionally there  is  coincident  involvement  of  its  serous  tunic. 

Tertiary  lesions  of  the  testis  begin  in  a  painless  and  insidious 
manner,  without  any  of  the  ordinary  signs  of  inflammation.  Some 
patients  complain  of  an  uneasy  sensation  in  the  organ,  but,  as  a  rule,  no 
attention  is  paid  to  the  progressing  affection  until  the  weight  of  the 
swelling  produces  a  moderate  pain  in  the  loins  and  inguinal  region. 
When  seen  early,  a  case  of  syphilitic  orchitis  or  sarcocele  presents  no 
well-marked  features.  The  organ  is  found  to  be  uniformly  swollen, 
and  quite  hard  and  firm  in  consistence,  and  it  is  less  sensitive  than 
in  a  normal  state.  In  some  cases  a  small  portion  of  the  apparent 
swelling  is  dependent  upon  hydrocele,  since  in  nearly  every  instance  of 
syphilitic  orchitis  there  is  a  slight  effusion  into  the  tunica  vaginalis. 
When  the  amount  of  fluid  is  considerable  it  may  be  necessary  to 
evacuate  it  by  puncture  before  a  satisfactory  examination  can  be  made  ; 
but  in  most  cases  we  may  by  firm  pressure  sufficiently  displace  the  fluid 
to  reach  the  body  of  the  testicle  and  determine  its  condition  by  palpa- 
tion. At  an  early  stage  of  the  disease  the  testicle  may  in  a  minority  of 
cases  be  found  to  contain  one  or  more  distinct  masses  of  induration, 
which  form  projections  upon  the  surface  of  the  size  of  the  head  of 
a  pin,  pea,  or  even  an  almond,  but  which  are  never  so  prominent  as 
to  change  the  general  contour  of  the  organ.  These  projections  are  due 
to  an  effusion  of  plastic  material,  of  the  same  nature  as  gummy  tumors, 
upon  the  surface  of  the  tunica  albuginea.  As  the  disease  progresses  the 
distinct  masses  of  induration  coalesce  and  form  a  hard,  resistant  tumor, 
which  preserves  to  a  great  extent  the  normal  shape  of  the  testicle.  In 
some  very  rare  cases  the  onset  of  syphilitic  orchitis  has  been  sudden 
and  attended  with  much  pain.  As  a  rule,  the  tumor  is  smooth  through- 
out its  whole  course,  in  which  event  the  clinical  picture  has  been  that 
of  acute  gonorrhceal  epididymo-orchitis. 

Testicular  tumors  of  late  syphilis  may  be  as  large  as  a  fist.  They 
are  ovoid  or  globular,  smooth,  and  firm  as  a  billiard-ball,  and  when 
elevated  in  the  palm  of  the  hand  they  seem  very  heavy.  As  a  rule,  no 
pain  is  present,  and  much  pressure  can  be  borne  without  discomfort  to 
the  patient. 

In  somewhat  rare  cases,  particularly  when  the  gummatous  infiltration 
is  localized  in  nodules  and  masses,  the  morbid  tissue  may  break  down 
and  an  abscess-cavity  be  left.  In  some  cases  excessive  proliferation  of 
the  tissues  occurs,  and  a  fungus  of  the  testicle  is  produced. 


THE  TESTIS.  657 

The  course  of  this  affection  is  exceedingly  chronic,  frequently  last- 
ing for  several  years.  The  sexual  desires  are  not  changed  unless  the 
lesion  has  made  great  progress  in  both  testicles. 

When  recognized  at  a  sufficiently  early  period,  syphilitic  orchitis 
may  almost  invariably  be  arrested  and  the  organ  restored  to  its  original 
integrity.  If  left  to  itself,  it  most  frequently  terminates  in  obliteration 
of  the  seminiferous  tubules  and  complete  or  partial  atrophy  correspond- 
ing to  the  extent  of  the  adventitious  deposit ;  or,  again,  the  parenchyma 
of  the  gland  may  degenerate  into  fibrous,  cartilaginous,  or  even  osseous 
tissue. 

Diagnosis. — The  smooth  and  hard  syphilitic  orchitis  is  generally 
easily  recognized.  In  a  given  case  it  is  well  to  bear  in  mind  that  a  very 
firm  hydrocele  tumor  with  thick  walls  may  be  mistaken  for  syphilitic 
sarcocele,  and  that  cystic  sarcoma,  villous  cancer,  and  carcinoma,  and 
exceptionally  tuberculosis  of  the  testis,  may  exist  in  the  shape  of 
smooth,  round,  ovoid,  and  pear-shaped  swellings,  which,  at  the  period 
of  development  and  before  degenerative  changes  have  taken  place,  may 
in  every  particular  resemble  the  syphilitic  testicle. 

Localized  nodular  gummatous  infiltration  may  be  mistaken  for  tuber- 
culosis. In  many  cases  of  syphilis  no  history  can  be  obtained,  and  in 
cases  of  malignant  disease  it  also  may  be  absent.  It  is  well,  therefore, 
in  all  cases  of  chronically  enlarged  testis  where  the  history  is  doubtful, 
to  cause  the  patient  to  undergo  a  carefully  watched  but  sufficiently  vig- 
orous local  and  general  antisyphilitic  treatment.  If  syphilis  exists, 
improvement  will  soon  be  noted,  and  in  most  cases  a  brilliant  cure  will 
be  obtained.  When,  after  a  thorough  tentative  antisyphilitic  treat- 
ment, the  testicular  swelling  remains  uninfluenced  or  increases  in  size, 
the  surgeon  may  quite  confidently  conclude  that  the  case  is  one  of 
malignant  disease  or  of  tuberculosis.  In  malignant  disease  there  is 
no  enlargement  of  the  inguinal  ganglia  until  the  process  has  extended 
to  the  scrotum,  and  in  late  syphilis  the  condition  is  similar.  In  many 
cases  of  syphilitic  sarcocele  there  is  no  evidence  of  ill-health,  which 
will  generally  be  noted  in  the  other  classes  of  cases  just  mentioned. 

We  have  no  precise  knowledge  of  the  effects  of  syphilis  upon  the 
prostate,  seminal  vesicles,  and  bladder. 

Treatment. — This  should  be  actively  pushed.  Iodide  of  potassium 
in  large  doses  or  the  mixed  treatment  may  be  given  internally.  Locally 
the  organ  should  be  enveloped  in  lint  copiously  smeared  with  mercurial 
ointment  and  supported  by  a  snug  suspensory  bandage. 

42 


CHAPTER   XLVI. 

SYPHILITIC  DEGENERATION  OF  BLOODVESSELS. 

ANEURYSM. 

Within  the  past  twenty  years  the  conviction  has  been  growing  in 
the  medical  mind  that  syphilis  is  an  active  and  frequent  factor  in  the 
production  of  aneurysm.  This  view,  at  first  based  on  clinical  obser- 
vations, has  since  been  confirmed  by  the  results  of  microscopical  studies. 
With  the  expansion  of  our  knowledge  of  the  pathology  of  syphilis  the 
fact  that  this  infection  during  its  whole  course  largely  attacks  the 
bloodvessels  has  called  particular  attention  to  it  as  a  primary  cause  of 
aneurysm. 

The  aorta  is  the  vessel  most  frequently  attacked ;  but  the  radial,  tem- 
poral, cerebral,  and  popliteal  arteries  are  also  frequently  involved. 

Many  cases  have  been  reported  in  which,  undoubtedly,  syphilis  was 
the  etiological  factor.  Then,  again,  there  are  cases  on  record  in  which 
it  is  difficult  to  eliminate  the  influence  of  trauma,  gout,  rheumatism, 
lead-poisoning,  alcoholism,  and  arteriosclerosis.  In  some  cases  there 
can  be  no  doubt  that  several  factors,  including  syphilis,  were  the  under- 
lying cause  of  the  arterial  degeneration. 

In  considering  the  influence  of  syphilis  in  the  causation  of  aneurysm 
it  is  not  only  necessary  to  bear  in  mind  the  factors  mentioned,  but  also 
the  conditions  of  life  of  the  patients.  In  soldiers  there  is  an  enforced 
constriction  of  the  chest  which  may  predispose  to  aortic  degeneration. 
In  other  walks  of  life  a  man's  duties  may  require  him  to  assume  posi- 
tions which  may  react  upon  the  vessels  of  the  chest. 

It  is  necessary  to  remember  that  aneurysmal  degeneration  is  usually 
of  late  development,  although  it  may  occur  early  and  during  the 
secondary  period. 

PHLEBITIS. 

The  veins  are  attacked  by  syphilis  in  much  the  same  way  that  the 
arteries  are,  in  both  the  secondary  and  tertiary  stages. 

One  or  many  veins  may  be  attacked  simultaneously  or  in  succession. 

The  lesion  consists  of  phlebitis  or  periphlebitis,  and  cases  are  on 
record  in  which  the  saphenous,  crural,  cephalic,  and  basilic  veins  were 
attacked.  The  large  veins  of  the  extremities,  particularly  the  legs,  are 
in  some  instances  involved. 

658 


GANGRENE  AND   GANGRENOUS   ULCERS.  659 

The  vessel  is  found  to  be  much  swollen,  firm,  and  cord-like.  It  may 
be  the  seat  of  slight  pain,  and  rarely  there  are  symptoms  of  acute 
inflammation.  In  many  cases  only  a  few  inches  of  the  vein  are  in- 
volved, but  the  whole  continuity  of  the  vessel  may  be  attacked. 

GANGRENE  AND  GANGRENOUS    ULCERS. 

In  some  cases  of  syphilis,  as  a  result  of  the  changes  in  the  coats  of 
arteries  and  veins,  gangrene  is  produced,  and  portions  of  the  integu- 
ment and  of  the  extremities  are  destroyed. 

Until  within  recent  years  all  ulcerations  occurring  in  syphilitic  sub- 
jects were  regarded  as  evidences  of  the  breaking  down  of  specific 
infiltrations.  To-day  we  clearly  recognize  the  fact  that  spontaneous 
gangrene  of  the  skin  and  its  resulting  ulcers  may  be  due  to  syphilitic 
arteritis  or  to  endarteritis  obliterans. 

This  degenerative  condition  usually  begins  in  individuals  of  poor 
nutrition,  in  those  who  are  debilitated  in  consequence  of  bad  regimen 
or  excesses,  and  in  subjects  who  have  not  been  properly  treated  and 
who  live  in  squalor. 

The  first  evidence  of  syphilitic  cutaneous  gangrene  is  a  mottling, 
with  perhaps  some  scaling  of  the  skin.  The  color  changes  to  a 
greenish-brown,  and  finally  becomes  blackish-brown.  In  some  cases 
the  resulting  eschar  is  soft  and  succulent  ;  in  others  it  is  tough,  dry, 
and  withered.  Very  soon  separation  occurs  at  the  base  and  the  periph- 
ery of  the  lesion,  and  in  a  few  days  or  a  week  or  two  the  slough 
falls  out,  and  a  deep  punched-out  ulcer  with  an  uneven,  anfractuous, 
and  dirty  surface  is  left.  The  surrounding  skin  may  be  red  and  oede- 
matous. 

In  some  cases  there  is  local  pain  ;  in  others  want  of  sensibility  and 
coldness  of  the  parts  are  complained  of. 

The  vessels  of  the  extremities  are  the  ones  most  commonly  attacked. 

Several  cases  have  been  published  in  which  symmetrical  gangrene 
of  the  fingers  (the  so-called  "  Raynaud's  disease  ")  has  been  observed 
in  syphilitic  subjects. 


CHAPTER   XLVII. 

SYPHILITIC  AFFECTIONS  OF  THE  NERVOUS  SYSTEM. 

Syphilitic  nervous  affections  may  be  developed  as  early  as  the  sixth 
month  and  as  late  as  the  twentieth  year  after  infection.  They  are  seen 
more  frequently  in  men  than  in  women,  and  are  most  common  between 
the  ages  of  twenty  and  thirty,  simply  because  syphilis  is  most  likely  to 
be  contracted  at  this  period  of  life. 

Syphilis  does  not  primarily  attack  the  cells  of  the  nervous  system, 
but  begins  in  the  vessels  and  connective  tissues  of  these  structures. 
The  brain  is  more  frequently  attacked  than  the  spinal  cord.  Our 
knowledge  of  the  effect  of  syphilis  upon  the  cerebellum  is  as  yet  rather 
limited. 

The  prominence  and  constancy  of  some  of  the  nervous  disorders 
of  syphilis  enable  us  to  recognize  them  as  distinct  affections — namely, 
subacute  meningitis,  hemiplegia,  epilepsy,  paraplegia,  and  aphasia,  and 
certain  others  of  minor  importance. 

PREDISPOSING  CAUSES  OF  SYPHILIS  OF  THE  NERVOUS 

SYSTEM. 

Nervous  symptoms  are  especially  likely  to  appear  in  persons  of  a 
neurotic  or  neuropathic  constitution,  which  may  be  hereditary  or 
acquired.  Chorea,  migraine,  apoplexy,  melancholy,  and  neuralgia  are 
common  features  in  the  family  history  of  such  individuals.  Those  who 
have  previously  had  some  simple  nervous  affection  are  particularly  liable, 
when  infected  by  syphilis,  to  the  development  of  specific  nervous  symp- 
toms. Protracted  mental  anxiety  and  strain,  depressing  emotions,  sexual 
excesses,  the  abuse  of  alcohol  and  of  narcotics,  have  been  known  to  act 
as  predisposing  causes.  Of  diseases,  those  accompanied  or  followed  by 
cerebral  congestion,  also  malaria  and  other  conditions  producing  cachexia, 
may  act  indirectly.  Sunstroke  and  injuries  of  the  skull  may  be  in- 
cluded, as  well  as  the  gouty  diathesis,  particularly  in  elderly  persons 
and  in  those  in  whom  gouty  cerebral  symptoms  have  been  prominent. 

The  inadequacy  or  the  absence  of  treatment  in  relation  to  the  invasion 
of  the  nerve-centres  by  syphilis  should  be  observed.  In  reading  the 
histories  of  cases  thus  far  reported  it  is  found  that  in  many  no  treat- 
ment at  all  had  been  attempted,  in  some  the  treatment  had  been  insuf- 
ficient, while  in  very  few  had  it  been  carried  on  vigorously. 

The  nervous   phenomena  of  syphilis  generally  originate  in  lesions 

660 


CAUSES  OF  SYPHILIS   OF  THE  NERVOUS  SYSTEM.  661 

developed  in  one  or  more  of  the  following  structures  :  the  cranial  bones 
and  vertebrae,  the  dura  mater,  the  arachnoid  and  pia  mater,  the  brain 
and  cord,  the  arteries,  the  nerves. 

The  Bones. 

Any  lesion  seated  on  the  inner  surface  of  the  cranium  or  vertebrae 
may  excite  inflammation  of  the  membranes,  and  may  finally  lead  to 
morbid  changes  in  the  brain  itself  and  in  the  spinal  cord.  The  most 
frequent  lesions  are  nodes,  exostoses,  caries,  and  necrosis. 

The  Dura  Mater. 

The  dura  mater,  being  a  fibrous  membrane,  is  peculiarly  susceptible 
to  the  syphilitic  poison.  The  changes,  which  usually  consist  of  thick- 
ening due  to  increased  cell-growth,  roughening  of  the  inner  surface  of 
the  membrane,  and  abdominal  vascularity,  are  generally  not  striking. 
In  some  cases  the  membrane  has  a  brownish-red  color  and  gelatinous 
appearance,  but  its  structure  remains  firm. 

The  extent  of  the  tissue  involved  and  the  amount  of  thickening 
vary,  but  are  generally  considerable. 

The  dura  mater  may  be  exclusively  affected,  or  the  disease  may 
invade  the  inner  table  of  the  skull  and  the  arachnoid,  or  the  dura  mater 
may  be  secondarily  affected  by  processes  beginning  in  the  arachnoid  and 
pia  mater.  In  the  case  of  nodes  of  the  inner  table  the  dura  mater  is 
found  thickened  and  abnormally  adherent. 

The  syphiloma  may  form  a  circumscribed  tumor  or  may  be  diffused 
over  a  large  area. 

The  portion  of  the  membranes  enveloping  the  brain  is  more  often 
involved  than  that  covering  other  parts.  There  may  be  but  one  focus 
of  disease  or  several  ;  in  the  latter  case  they  are,  as  a  rule,  unsymmetrical. 

Syphilomata  of  the  spinal  dura  mater  have  an  origin  and  pursue  a 
course  similar  to  those  of  the  cerebral. 

The  Arachnoid  and  Pia  Mater. 

In  simple  hyperemia  of  the  pia  mater  the  arachnoid  may  not  be 
involved,  but  when  the  process  advances  to  cell-proliferation  it  is  impos- 
sible to  demonstrate  a  line  of  demarcation  between  the  two  membranes. 

In  most  cases  the  lesions  of  these  membranes  consists  of  congestion 
and  visible  enlargement  of  the  vessels,  followed  by  increase  of  connective 
tissue  and  consequent  thickening  ;  but  sometimes  gummatous  infiltration 
supervenes,  constituting  a  gummous  meningitis. 

More  or  less  change  in  the  subjacent  nervous  tissue  always  follows, 
and  the  lesion  may  involve  the  dura  mater  and  the  cranial  bones. 

This  is  perhaps  the  most  frequent  syphilitic  nervous  lesion.      It  is 


662         SYPHILITIC  AFFECTIONS   OF  THE  NERVOUS  SYSTEM. 

found  in  single  or  multiple  patches,  distinctly  circumscribed,  of  round 
or  oval  shape,  and  of  various  sizes. 

When  multiple,  the  patches  are  scattered  irregularly,  most  frequently 
at  the  base,  in  the  anterior  and  middle  fossae,  less  frequently  on  the  con- 
vexity of  the  brain,  seldom  on  the  cord  and  medulla,  and  exceptionally 
on  the  cerebellum. 

The  Brain  and  Cord. 

The  changes  in  the  brain  and  cord  are  always  secondary  to  lesions 
of  the  bones,  of  the  meninges,  or  of  the  vessels,  and  consist  of  two 
kinds  of  softening,  the  red  and  the  white,  which  are  similar  to  these 
lesions  when  non-specific. 

The  softening  is  likely  to  be  more  superficial  when  the  lesion  begins 
in  the  meninges  than  when  it  originates  in  the  bones. 

A  primary  vascular  lesion  on  the  basal  surface  will  produce  much 
more  serious  and  extensive  structural  change  in  the  brain  than  one  at 
the  vortex,  for  the  reason  that  in  the  latter  situation  the  vessels  anasto- 
mose freely,  whereas  in  the  former  each  vessel  is  distributed  to  a  region 
which  has  no  other  source  of  nutrition. 

The  Arteries. 

The  changes  which  syphilis  produces  in  the  vessels  have  been 
described  (see  page  490  et  seq.). 

The  arteries  most  frequently  involved  are  the  large  vessels  at  the 
base  of  the  brain,  and,  for  reasons  already  given,  the  danger  to  an  ex- 
tensive portion  of  the  cerebral  mass  from  defective  nutrition  is  much 
greater  than  in  disease  of  arteries  distributed  to  the  convexity. 

The  morbid  change  is  rarely  confined  to  a  segment  of  the  artery,  but 
usually  involves  its  entire  circumference,  and  generally  from  an  inch  to 
an  inch  and  a  half  of  its  continuity.  Several  vessels  may  be  involved 
in  different  stages  of  the  lesion  or  only  one  may  be  affected. 

In  advanced  stages  of  the  morbid  process  the  vessel  is  found  to  be 
thickened,  rigid,  and  slightly  compressible,  and  may  even  have  a  nodu- 
lated appearance,  due  to  excessive  cellular  development  and  invasion  of 
the  outer  tunics  at  certain  points.  A  thickened  artery  of  small  size  may 
present  several  rounded  expansions  within  the  limit  of  an  inch. 

The  Nerves. 

The  cerebrospinal  nerves  may  be  involved  in  the  various  affections 
of  the  meninges  ;  they  may  be  encircled  by  gummy  tumors  ;  or  they  may 
be  compressed  by  swellings  of  the  bony  foramina.  The  resulting  symp- 
toms are  anaesthesia,  hypersesthesia,  analgesia,  neuralgia,  paralysis,  or 
disturbances  of  the  special  senses. 


HEMIPLEGIA.  663 

Syphilitic  lesions  being  most  frequent  in  the  neighborhood  of  the 
interpeduncular  space,  the  nerves  near  this  region  are  most  commonly 
involved.  The  third  pair  are  perhaps  most  often  affected,  the  first, 
second,  fourth,  and  sixth  quite  frequently,  while  syphilitic  changes  of 
the  seventh  pair,  or  facial  nerves,  are  rather  exceptional. 

We  know,  as  yet,  little  of  the  morbid  changes  caused  by  syphilis  in 
the  peripheral  nerves,  but  certain  clinical  facts  indicate  that  neuritis  and 
multiple  neuritis  occur  in  the  course  of  syphilis,  as  they  do  in  that  of 
other  infectious  diseases. 

The  sympathetic  nerves  may  undergo  two  varieties  of  change — one 
affecting  the  nerve-cells  and  characterized  by  pigmentary  and  colloid 
degeneration ;  the  other  consisting  of  a  connective-tissue  proliferation. 

SYPHILITIC  TUMORS  OF  THE  NERVOUS  SYSTEM. 

Two  forms  of  syphiloma,  or  syphilitic  tumor,  are  found  in  the  cranio- 
vertebral  cavity  which  differ  widely  in  gross  appearances,  but  are  com- 
posed of  similar  structural  elements.  These  tumors  are  usually  con- 
nected with  the  cerebrum  ;  they  have  rarely  been  found  in  the  medulla 
oblongata  or  in  the  cord,  but  chiefly  on  the  inferior  surface  of  the 
brain,  in  the  region  of  the  fissure  of  Sylvius. 

These  tumors  vary  greatly  in  number  and  in  size  ;  there  may  be  a 
single  one  or  the  surface  of  the  hemisphere  may  be  studded  with  large 
numbers  of  them,  resembling  the  condition  in  miliary  tuberculosis  ;  they 
may  be  of  the  size  of  a  pea  or  of  a  small  walnut.  They  are  usually 
round  or  oval,  but  in  some  situations  they  become  flattened. 

HEMIPLEGIA. 

One  of  the  most  frequent  phenomena  of  cerebral  syphilis  is  hemi- 
plegia, which  may  occur  as  early  as  the  third  month  or  as  late  as  twenty 
years  after  infection.  The  interference  with  the  motor  function  may  be 
slight  or  there  may  be  complete  loss  of  power.  It  is  generally  preceded 
by  a  stage  in  which  a  prominent  symptom  is  localized  headache,  often 
associated  with  many  of  the  other  symptoms  already  mentioned,  such  as 
mental  disturbance,  hebetude,  vertigo,  and  convulsions,  which  are  often 
immediately  followed  by  the  paralytic  stroke. 

In  some  cases  muscular  spasm,  a  form  of  preparalytic  chorea,  has 
been  observed  in  the  limbs  afterward  paralyzed.  For  instance,  the  arm 
may  be  jerked  in  various  directions,  or  the  patient  may  find  it  impossible 
to  place  the  foot  firmly  on  the  ground,  the  leg  being  jerked  suddenly 
from  under  him  when  he  attempts  to  stand.  In  other  cases  darting 
pains  are  felt  in  the  leg  or  arms,  or  constant  neuralgic  pain  may  exist 
in  some  part  of  the  limb,  or  there  may  be  numbness  or  tingling  in  the 
hands  and  feet,  with  areas  of  hyperesthesia  or  anaesthesia. 


664        SYPHILITIC  AFFECTIONS  OF  THE  NERVOUS  SYSTEM. 

In  cases  of  gradual  invasion  total  paralysis  seldom  occurs.  The 
patient  first  notices  that  he  is  losing  strength,  perhaps  in  his  fingers,  so 
that  he  finds  himself  unable  to  button  his  clothing  or  to  hold  a  pen 
firmly.  This  condition  may  continue  until  paralysis  comes  on,  or  it  may 
be  intermittent,  the  normal  strength  returning  at  intervals.  When  the 
leg  is  thus  affected  the  patient  naturally  has  more  or  less  difficulty  in 
walking.  Complete  hemiplegia  may  come  on  in  this  gradual  manner, 
but  is  generally  sudden  in  onset.  Sometimes  the  leg  is  affected  several 
hours  before  power  is  lost  in  the  arm.  The  reverse,  however,  is  infre- 
quent. Patients  are  usually  attacked  with  hemiplegia  when  engaged  in 
some  act  of  muscular  effort,  such  as  pulling  on  the  boots,  walking 
briskly,  reaching  for  some  object,  or  on  the  point  of  shooting  at  game. 
On  the  contrary,  the  attack  may  happen  during  the  night,  and  the 
patient  be  unable  to  rise  from  bed  in  the  morning. 

The  course  and  duration  of  hemiplegia  vary  greatly.  When  partial 
the  paralysis  may  gradually  improve,  and  even  disappear  spontaneously 
in  a  few  days ;  or,  as  improvement  takes  place,  the  opposite  side  may 
be  similarly  affected,  followed  by  recurrence  of  the  paralysis  on  the 
side  first  involved.  These  cases  are  accompanied  by  excessive  mental 
impairment,  and,  as  a  rule,  have  an  early  fatal  termination.  Syphilitic 
hemiplegia  is  caused  by  lesions  of  the  arteries,  and  in  cases  of  the 
latter  class  the  vessels  of  both  sides  of  the  brain  are  implicated. 

Disturbance  of  general  sensation  is  usually  limited,  but  instances  of 
slight-  loss  of  motor  power,  with  complete  loss  of  the  sensory  function, 
have  been  reported.  In  exceptional  cases  there  may  be  total  loss  of 
both  motion  and  sensation. 

A  great  variety  of  phenomena,  depending  upon  the  extent  and  situa- 
tion of  the  lesions,  may  accompany  syphilitic  hemiplegia,  such  as  paral- 
ysis of  various  nerves,  aphasia,  mydriasis,  optic  neuritis,  and  epilepsy. 
Mental  depression  seems  to  be  constant,  and  most  patients  either  display 
a  condition  of  complete  hebetude  or  are  excessively  emotional. 

Though  early  and  energetic  treatment  may  accomplish  the  relief  and 
even  the  cure  of  hemiplegia,  the  prognosis  is  greatly  influenced  by  the 
age  and  extent  of  the  lesion.  The  arteries  arising  from  the  circle  of 
Willis  supply  the  most  important  regions  of  the  brain,  and  are  most  fre- 
quently affected  by  syphilis ;  obviously  if  but  one  artery  is  involved  the 
prognosis  is  more  favorable  than  if  many  are  attacked.  The  number 
and  gravity  of  the  symptoms  will  usually  give  an  idea  of  the  extent 
of  the  lesion.  In  a  simple  case  of  hemiplegia  probably  only  one  or  two 
vessels  are  affected,  and  complete  recovery  may  take  place ;  but  when 
other  symptoms  indicative  of  extensive  disorganization  of  the  brain  are 
present  the  prognosis  is  less  favorable.  As  a  rule,  perfect  health  is  in 
no  case  restored,  although  the  patient  may  present  no  conspicuous  ill- 


EPILEPSY.  665 

ness.     We  may  say,  however,  that  the  prognosis  in  syphilitic  hemi- 
plegia is  better  than  in  the  simple  form. 

Diagnosis. — Syphilitic  hemiplegia  usually  occurs  much  earlier  in 
life  than  the  simple  variety,  which  is  not  commonly  seen  before  the  age 
of  forty  years.  It  should  be  remembered,  therefore,  that  syphilis  is 
the  cause  of  most  of  the  cases  of  hemiplegia  in  the  young  and  middle- 
aged.  The  fact  that  a  patient  rarely  loses  consciousness  when  attacked 
by  syphilitic  hemiplegia  is  an  additional  diagnostic  point  of  importance. 

EPILEPSY. 

This  is  of  frequent  occurrence  in  cerebral  syphilis,  and,  like  non- 
specific epilepsy,  presents  two  forms,  the  grand  mat  and  the  petit  mal. 
Headache,  increasing  in  severity,  always  precedes  an  attack.  The 
symptoms  of  the  severe  form  are  similar  to  those  of  the  non-specific 
variety,  consisting  of  sudden  loss  of  consciousness,  tonic  followed  by 
clonic  spasms,  facial  distortion,  foaming  at  the  mouth,  and  stertorous 
respiration.  According  to  some  authors,  the  epileptic  aura  and  cry 
are  absent.  Such  convulsions  occur  at  intervals,  and  frequently 
with  regularity  every  ten  days  or  once  a  month.  Instances  of  their 
regular  occurrence  in  the  evening  and  at  night  have  been  reported; 
but,  as  a  rule,  they  come  on  at  no  definite  time.  In  some  cases  con- 
sciousness returns  in  a  few  minutes ;  in  others  the  patient  remains  in 
a  stupid  condition  for  hours,  and  may  not  be  fully  restored  for  several 
days.  After  the  seizure  the  headache  may  be  much  less  severe  for 
a  time,  but  unless  treatment  is  adopted  its  intensity  soon  returns. 

The  course  of  syphilitic  epilepsy  is  uncertain,  and  may  be  greatly 
modified  by  treatment. 

When  convulsions  follow  a  long  prodromal  stage  in  which  symptoms 
of  mental  disturbance  have  been  particularly  severe,  the  prognosis 
is  rather  unfavorable ;  cases  in  which  they  follow  a  short  period  of 
headache  generally  yield  to  proper  treatment.  Tonic  spasms  may  pre- 
cede or  follow  an  attack  of  hemiplegia,  and  are  often  seen  in  connection 
with  permanent  or  intermittent  aphasia.  They  are  generally  caused 
by  pachymeningitis,  though  probably  in  some  cases,  as  claimed  by 
Jackson,  irritation  from  a  gumma  is  the  exciting  cause. 

The  intervals  of  syphilitic  epilepsy,  unlike  those  of  apparent  health 
in  the  simple  form,  are  marked  by  symptoms  of  mental  disturbance, 
which  tend  to  increase,  and  may  end   in  dementia. 

The  mild  form,  called  by  Charcot  partial  syphilitic  epilepsy,  may 
exist  independently  or  combined  with  the  severe  form.  The  paroxysm 
may  begin  either  with  a  twitching  of  one  side  of  the  face ;  a  turning  of 
the  tongue  to  one  side  ;  a  tendency  on  the  part  of  the  patient  to  whirl 
around  ;  extreme  giddiness  ;  general    trembling,  or  great  weakness  or 


666        SYPHILITIC  AFFECTIONS  OF  THE  NERVOUS  SYSTE3I. 

cramps  of  the  extremities,  which  is  followed  by  loss  of  consciousness 
and  a  convulsion  consisting  either  of  slight  muscular  tremor  or  of  gen- 
eral tonic  spasm.  The  seizure  may  be  limited  to  a  single  limb  or  to  one 
side  of  the  body,  and  in  some  cases  only  amounts  to  slight  rigidity. 
The  severity  and  length  of  the  attack  are  much  less  than  in  the 
grand  mat. 

Frequently  there  is  no  convulsion,  but  the  patient,  while  talk- 
ing or  performing  any  act,  becomes  unconscious  and  is  seen  to  stare 
vacantly.  If  sitting,  he  becomes  motionless;  if  walking,  he  does  not 
fall,  but  proceeds  in  an  aimless  manner ;  and  if  in  the  midst  of  con- 
versation, he  suddenly  becomes  obtuse  and  fails  to  comprehend  questions 
addressed  to  him.  While  in  this  condition,  which  may  last  only  a 
few  seconds  or  as  long  as  twenty  minutes,  he  may  perform  rational 
acts,  such  as  paying  properly  for  a  purchased  article,  or  he  may  even 
walk  without  staggering,  and  when  his  senses  are  restored  he  may  recall 
indistinctly  or  not  at  all  what  he  has  said  or  done. 

The  diagnostic  points  of  syphilitic  epilepsy  are — 1,  the  history  of 
the  patient ;  2,  the  paroxysmal  headache ;  3,  the  frequency  of  mental 
disturbance  ;  4,  the  frequent  coexistence  of  optic  neuritis,  hemiplegia, 
aphasia,  and  paralyses  of  various  nerves  ;  5,  the  age  of  the  patient ;  6, 
the  result  of  treatment. 

Simple  epilepsy  is  usually  developed  before  puberty,  whereas  that 
caused  by  syphilis  generally  occurs  between  the  ages  of  twenty  and 
thirty,  .the  period  when  syphilis  is  most  frequently  contracted.  The 
former  is  either  uninfluenced  or  aggravated  by  iodide  of  potassium 
and  mercurials,  whereas  the  influence  of  these  drugs  on  the  latter  is 
favorable  and  in  some  cases  curative. 

PARAPLEGIA. 

Though  the  spinal  cord  is  attacked  by  syphilis  less  frequently  than 
the  brain,  at  least  one-half  the  cases  of  paraplegia  are  of  syphilitic 
origin. 

The  symptoms  are  not  strongly  marked.  The  patient,  who  may 
suffer  from  pain  in  the  back,  notices  slight  weakness  of  the  lower 
extremities,  and  may  also  complain  of  one  or  more  of  the  following 
symptoms  :  darting  pains  and  spasms  in  the  legs ;  numbness,  tick- 
ling, or  aching  pains  in  the  feet ;  hyperesthesia,  anaesthesia,  dermatalgia, 
and  formication.  Loss  of  co-ordinating  power  may  be  observed.  There 
is  usually  progressive  weakness  in  the  expulsive  power  of  the  rectum 
and  bladder.  This  condition  may  remain  stationary  for  a  long  time  or 
it  may  improve  temporarily,  but  unless  treatment  is  adopted  complete 
paralysis  of  both  legs  finally  ensues.  On  the  other  hand,  the  develop- 
ment of  paraplegia  may  be  much  more  rapid. 


APHASIA.  667 

General  sensation  may  be  preserved  slightly  impaired  or  wholly  lost. 
Exceptionally  it  is  destroyed  while  the  motor  function  remains  perfect. 
After  the  establishment  of  complete  paralysis  there  may  be  short  inter- 
vals of  slightly  restored  power,  or  jerking  of  the  muscles  may  be  present. 

Paraplegia  may  be  the  only  manifestation  of  syphilis  existing  at  this 
time,  but  frequently  there  are  evidences  of  lesions  in  the  brain,  such  as 
headache,  vertigo,  mental  impairment,  paralysis  of  one  or  more  cranial 
nerves,  particularly  those  supplying  the  muscles  of  the  eyes,  or  optic 
neuritis.  Mydriasis  has  also  been  observed.  The  presence  of  any  of 
these  latter  symptoms  confirms  the  diagnosis  of  syphilis,  which  is  ordi- 
narily less  clear  in  this  than  in  other  nervous  affections  of  specific 
origin.  Careful  inquiry  into  the  history  and  age  of  the  patient  is  de- 
manded. Simple  idiopathic  paraplegia  generally  occurs  later  in  life 
than  the  syphilitic  form ;  and  the  latter,  like  all  specific  nervous  affec- 
tions, is  greatly  influenced  and  frequently  cured  by  treatment,  which 
should  be  adopted  early  in  all  cases,  even  in  those  of  doubtful  char- 
acter. 

The  prognosis,  unless  treatment  has  been  long  delayed,  is  favorable. 

The  causes  of  syphilitic  paraplegia  are  lesions  of  the  vertebrae,  of 
the  spinal  meninges,  and  tumors,  which  by  pressure  on  the  cord  lead  to 
myelitis  and  softening. 

Cases  thus  far  observed  indicate  that  paraplegia  is  a  later  manifesta- 
tion of  syphilis  than  hemiplegia  and  epilepsy,  though  probably  the 
lesions  which  cause  it  may  be  developed  as  early  as  within  the  first  year 
of  infection.  In  the  majority  of  recorded  cases  its  invasion  has  occurred 
after  the  sixth  year  of  infection.     It  may,  of  course,  occur  much  later. 

APHASIA. 

Various  disturbances  of  speech,  included  under  the  term  "  aphasia," 
frequently  occur  in  the  course  of  syphilis  of  the  nervous  system.  These 
may  consist  merely  of  hesitation  in  speaking,  called  embarras  de  parole, 
or  of  inability  to  remember  certain  words  in  writing  and  in  speaking, 
or  of  the  use  of  utterly  inappropriate  words  on  all  occasions. 

Syphilitic  aphasia  may  be  continuous  or  intermittent,  and  alwavs 
accompanies  other  symptoms  which  determine  its  origin,  since  it  pre- 
sents in  itself  no  diagnostic  features. 

The  prognosis  depends  to  a  great  extent  upon  the  early  adoption  of 
antisyphilitic  treatment. 

LOCOMOTOR  ATAXIA. 

Investigations  made  within  recent  years  clearly  show  that  in  60  or 
70  per  cent,  of  cases  of  locomotor  ataxia  the  patients  had  suffered  more 
or  less  remotely  from   syphilis.     This  affection  is   due  to  connective- 


668         SYPHILITIC  AFFECTIONS   OF  THE  NERVOUS  SYSTEM. 

tissue    increase   in    the    neuroglia,    which    is    so  commonly  caused  by 
syphilis. 

The  syphilitic  form  of  this  disorder  is  similar  in  its  clinical  history 
to,  and  is  as  rebellious  to  treatment  as,  the  simple  form. 

CHOREA. 

The  spasmodic  muscular  movements  caused  by  syphilis  are  irregular 
and  occasional,  and  never  constitute  true  chorea.  Preparalytic  chorea, 
characterized  by  spasmodic  contractions  without  loss  of  consciousness, 
preceding  an  attack  of  hemiplegia  or  paraplegia,  has  been  referred  to ; 
similar  contractions  not  infrequently  follow  these  paralyses,  and  the 
condition  is  then  called  post-paralytic  chorea. 

The  spasms  vary  in  intensity  from  a  mere  twitch  to  a  decided  con- 
vulsion, and  maybe  limited  to  an  arm,  or  may  at  the  same  time  include 
the  face,  or  they  may  occur  unilaterally  in  the  arm  and  the  leg.  They 
do  not,  as  a  rule,  become  general,  and  always  coexist  with  other  symp- 
toms of  graver  import. 

DEMENTIA. 

Syphilis  produces  a  morbid  mental  condition  which  consists  of  an 
association  of  intellectual,  sensory,  and  motor  disturbances,  evidenced 
by  numerous  and  complex  symptoms.  The  intellectual  disorder  is  in- 
dicated by  cerebral  excitement  and  exaltation  of  ideas  with  incoherence, 
and  by  gayness  of  spirits  alternating  with  hebetude,  together  with 
delirium  and  even  mania.  The  motor  disturbances  are  well  marked, 
and  consist  of  uncertain  movements  without  paralysis,  trembling,  and 
imperfect  prehensile  power  of  the  hands,  sudden  loss  of  equilibrium, 
imperfect  co-ordination,  staggering  gait,  and  hesitating  speech.  Besides 
these,  there  are  frequently  special  affections,  such  as  trembling  of 
muscles  and  partial  paralysis,  ephemeral  or  persistent,  and  also  certain 
svmptoms  of  cerebral  congestion  ;  of  the  latter  may  be  mentioned  a 
sense  of  weight  and  pain  in  the  head,  dizziness,  sudden  dazzling  sen- 
sations, vertigo,  and  various  impairments  of  sight  and  hearing  ;  to  these 
should  be  added  epileptic  and  epileptiform  convulsions  and  sudden 
seizures  of  an  apoplectic  character.  Of  course,  we  never  meet  with  all 
the  above  symptoms  in  combination,  but  in  all  cases  many  of  them  are 
associated. 

The  peculiarities  of  syphilitic  dementia  are  that  the  paralytic 
symptoms  predominate  ;  that  symptoms  appear  in  a  capricious  and 
irregular  manner,  fibrillary  contractions  of  the  facial  and  lingual  muscles 
being  absent ;  that  there  are  no  well-defined  exalted  ideas ;  and  that 
behind  all  there  is  a  syphilitic  cachexia. 

Treatment. — It  may  be  well  hereto  emphasize  the  point  that  in  the 


DEMENTIA.  669 

treatment  of  syphilitic  nervous  affections,  particularly  those  occurring 
within  the  early  years  of  the  infection,  we  must  not  place  our  whole 
trust  in  the  iodide  of  potassium  and  ignore  mercury.  This  latter  agent 
is  sometimes  invaluable  in  these  cases.  By  its  use,  together  with  that 
of  the  iodide,  it  will  in  many  cases  not  be  necessary  to  give  the  latter 
drug  in  such  large  doses  as  has  sometimes  been  done.  Mercurial  oint- 
ment inunctions  and  hypodermic  injections  of  the  bichloride  of  mercury 
are  in  many  cases  of  signal  benefit.  Iodide  of  potassium  internallv  and 
mercury  locally  applied  should  not  be  forgotten  in  brain,  medullary, 
and  neuritic  syphilis.  It  is  important  in  the  treatment  of  cases  of 
cerebral  syphilis  that  the  mercurial  ointment  should  be  rubbed,  if  pos- 
sible, upon  the  neck  or  upper  portions  of  the  body,  in  order  to  act  upon 
the  lymphatic  system  as  near  as  possible  to  the  brain.  With  care  and 
attention  to  the  local  reaction  which  the  inunctions  may  induce  (but  not 
necessarily),  the  region  of  the  neck,  and  even  the  scalp,  may  be  utilized 
for  sufficiently  long  periods  to  insure  amelioration  of  the  symptoms. 

Not  only  in  cases  of  syphilitic  meningeal  lesions,  but  also  in  those 
of  arterial  degeneration,  of  extensive  and  localized  paralyses,  epilepsy, 
dementia,  and  of  the  various  syphilitic  neuralgias,  will  this  combination 
treatment  prove  beneficial,  and  very  often  be  followed  by  the  most 
prompt  and  brilliant  results.  The  regional  use  of  the  inunctions  is,  in 
my  judgment,  a  great  aid  in  promptness  of  cure. 

The  early  onset  of  symptoms  referable  to  the  cerebrospinal  system  in 
many  instances  necessitates  the  early  use  of  the  iodide  of  potassium. 

Syphilitic  headaches  will  frequently  be  found  very  persistent  and 
rebellious  to  treatment  when  mercury  is  given  by  the  mouth.  In  some 
few  cases  calomel,  in  doses  of  A  or  i  grain  every  three  or  four  hours, 
may  prove  beneficial,  but  the  danger  of  salivation  is  always  to  be 
feared  if  its  use  is  prolonged.  Mercurial  inunctions  into  the  neck  and 
temples  will  usually  prove  very  beneficial,  and  synchronously  iodide  of 
potassium   in  increasing  doses  should  be  given. 

Iodide  of  potassium  may  be  taken  in  milk,  or  in  Vichy  water,  and  in 
cases  of  weak  stomach  may  be  combined  with  Fairchild's  essence  of 
pepsin,  and  also  with  bitter  tonics.  In  some  cases  a  dose  of  30  grains 
three  or  four  times  a  day  wrill  have  the  desired  effect.  In  obstinate 
cases,  however,  the  remedy  must  be  pushed  until  amelioration  in  the 
condition  is  produced  or  the  obstinacy  of  the  case  shows  that  such  dis- 
organization has  been  produced  by  the  syphilitic  process  that  further 
improvement  is  hopeless.  As  much  as  1J  ounces  daily  have  been 
required  in  many  cases  to  produce  a    ure. 

Besides  the  treatment  here  outlined,  medication  directed  to  concomi- 
tant and  consecutive  symptoms  and  conditions  will  be  required,  and 
should  be  instituted  according  to  the  indications  presented. 


CHAPTER   XLVIII. 

THE  GENERAL  METHODICAL  TREATMENT  OF  SYPHILIS. 

Xo  statement  can  be  made  with  more  emphasis  or  with  a  greater 
foundation  of  truth  than  that  the  proper  time  to  begin  systematic  medi- 
cation in  syphilis  is  the  date  at  which  general  manifestations  show  them- 
selves. There  is  no  advantage  or  possible  benefit  lost  to  the  patient  by 
withholding  mercury  until  the  onset  of  the  second  stage,  nor  is  the 
patient  thereby  put  in  jeopardy,  present  or  future,  nor  are  his  chances 
for  ultimate  permanent  cure  in  any  way  impaired.  On  the  other  hand, 
syphilis  will  be  more  orderly  and  conspicuously  more  amenable  to 
treatment,  and  his  physician  will  not  grope  in  the  dark,  and  will,  if  he 
promptly  attacks  the  disease  in  the  conservative  but  vigorous  manner 
soon  to  be  detailed,  be  spared  the  doubt  and  uncertainty  of  mind 
which  are  the  inevitable  lot  of  those  who  treat  the  disease  prematurely. 
Then,  again,  when  a  patient  sees  convincing  proof  that  he  is  syphilitic 
he  usually  persists  in  following  treatment  until  he  is  pronounced  cured. 

The  date,  therefore  (as  a  general  rule),  at  which  the  treatment  of 
syphilis  should  be  begun  is  that  at  which  the  disease  gives  evidence  of 
the  general  infection  of  the  economy — namely,  as  soon  as  the  generalized 
rash  appears,  together  with  the  other  manifold  symptoms  of  the  second- 
ary period.  Exceptions  to  this  rule  sometimes  present  themselves  in 
cases  where  chancres  interfere  with  the  function  of  important  organs; 
when  their  continued  presence  renders  other  persons  liable  to  infection; 
when  marital  relations  and  exigencies  render  the  removal  of  the  initial 
lesion  imperative ;  or  when  syphilis  is  contracted  in  the  early  weeks  of 
pregnancy. 

If  the  patient  is  under  observation  during  the  course  of  the  chancre, 
much  can  be  done  for  him  in  advance  by  the  surgeon.  At  this  time 
he  can  be  prepared,  if  necessary,  for  the  coming  ordeal  by  a  prepara- 
tory tonic  course  ;  or,  if  there  are  indications  of  gastro-intestinal  impair- 
ment or  debility,  measures  to  remedy  them  may  be  instituted.  Then, 
again,  in  this  period,  if  there  are  very  much  swollen  lymphatics  or 
ganglia  (and  they  will  be  found  in  association  with  the  chancre),  a  well- 
directed  external  regional  treatment  may  be  followed.  To  this  end 
plasters  of  mercurial  ointment  spread  upon  lint  may  be  used.  This 
regional  treatment  will  have  no  perceptible  effect  upon  the  general 
development  of  the  infection.     At  this  time  also  the  condition  of  the 

670 


THE   GENERAL  METHODICAL    TREATMENT  OF  SYPHILIS.     671 

mouth,  gums,  teeth,  and  pharynx   should  be  inquired  into,  and  these 
parts  should  be  put  as  nearly  as  possible  into  a  condition  of  health. 

Before  putting  a  patient  upon  general  antisyphilitic  treatment  it  is 
well  for  the  physician  to  place  before  him  certain  facts  as  to  his  condi- 
tion and  his  duties,  and  to  forecast  for  him,  as  far  as  possible  or  prudent, 
his  future  pathological  balance-sheet,  so  that  he  may  know  clearly  what 
he  has  to  do,  what  he  has  to  fear,  and  what  he  may  expect.  With  the 
onset  of  secondary  syphilis  a  most  important  and  eventful  epoch  in  the 
life  of  the  patient  begins,  and  much  can  be  done  for  him  by  a  little 
kindliness  and  common  sense.  The  physician  should  impress  upon 
the  patient  the  gravity  of  his  disease  and  prepare  him  for  the  ordeal 
which  is  in  store  for  him.  He  must  be  made  to  understand,  in  a 
gentle,  kindly  manner,  that  the  ensuing  two  years  at  least  are  the  most 
critically  momentous  ones  in  his  whole  life,  and  that  his  future  health 
and  happiness,  and  those  of  his  family,  depend  upon  his  care  of  himself 
during  this  trying  epoch.  It  is  cruel  and  unnecessary  to  paint  a  dismal 
and  lugubrious  picture  to  these  patients,  or  by  word  or  manner  to 
depress  or  discourage  them.  We  are  in  the  position,  as  a  result  of 
advanced  therapeutics,  to  speak  encouragingly  and  even  brightly  of 
their  future,  and  to  hold  out  to  them  the  assurance  that  the  ordeal  of 
treatment  will  not  be  irksome  or  painful,  and  that  a  cure  is  in  store 
for  them.  "We  can  tell  our  patients  truthfully  that  two  or  two  and  a 
half  years  of  careful,  methodical,  watchful  treatment  will  be,  if  they  but 
conform  to  its  regulations,  sufficient  to  cure  them  of  their  disease.  As 
a  result  of  treatment  they  will  see  the  syphilitic  lesions  disappear  and 
fail  to  return,  they  will  enter  into  a  period  of  health  in  which  there  are 
no  signs  whatever  of  syphilis  about  them,  and  they  will  thus  remain 
and  will  possess  the  power  of  procreating  healthy  children.  The 
requirements  for  this  gratifying  state  and  for  this  future  immunity  are  a 
fairly  good  state  of  health  previous  to  infection,  docility  and  loyalty 
of  the  patient  to  his  physician,  and  a  treatment  begun  sufficiently  early 
and  carried  out  in  a  watchful,  thorough  manner.  This  is  the  tripod  upon 
which  his  future  happiness  rests.  In  the  treatment  of  syphilis  the  duties 
of  the  physician  and  patient  are  reciprocal.  While,  therefore,  in  the 
majority  of  cases,  particularly  those  of  the  intelligent  and  well-to-do 
classes,  we  are  warranted  in  giving  a  hopeful  and  satisfactory  prognosis, 
there  are  cases  in  which,  under  most  favorable  circumstances,  the 
progress  toward  cure  is  slow,  often  disappointing  and  halting,  and  at- 
tended with  much  discomfort,  debility,  and  illness.  But  even  in  these 
cases,  trying  and  often  discouraging  alike  to  the  patient  and  the  physi- 
cian, there  is  usually  no  necessity  for  doubt  or  despair,  since  with  the 
rich  therapeutic  armamentarium  at  our  command  we  are  enabled  to 
adapt  ourselves  to  urgent  necessities,  exigencies,  and  emergencies,  and 


672     THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS. 

even  to  cope  with  formidable  crises.  In  his  early  interviews  with  a 
syphilitic  patient  it  is  the  duty  of  the  physician  to  make  a  careful  study 
of  the  man,  to  acquaint  himself  with  his  temperament,  his  standard  of 
health  and  vitality,  his  power  of  resistance  to  disease  and  bodily  strain 
— in  fact,  his  mental  and  physical  stamina,  modes  of  life,  tendencies, 
habits,  and  surroundings,  and  his  duties,  obligations,  cares,  and  respon- 
sibilities— since  from  such  a  study  much  valuable  knowledge  is  gained. 

It  must  always  be  remembered  that  weakly,  cachectic  persons  of  poor 
fibre ;  flabby  subjects  ;  those  who  may  be  classed  generally  as  under- 
weight individuals;  persons  with  very  light  and  sandy  complexion ;  those 
suffering  from  rheumatic,  gouty,  tuberculous,  neurotic,  malarious,  or 
other  adynamic  conditions  or  influences ;  those  having  visceral  disease 
of  any  kind  or  any  inherited  or  acquired  morbid  tendency  ;  and  particu- 
larly persons  addicted  to  alcoholic  indulgences — are  liable  to  suffer 
more  or  less  severely  from  syphilis,  and  that  in  such  cases  the  prognosis 
is  less  favorable  and  a  longer  time  for  cure  may  be  required. 

Besides  its  specific  poison,  syphilis  tends  in  many  cases  to  produce 
in  the  economy  anaemia,  cachexia,  and  even  a  condition  of  marasmus. 
Though  there  are  some  patients  in  whom  it  does  not  produce  debility, 
and  who  seem  as  well  as  they  ever  were,  we  must  always  be  on  the 
lookout  for  its  depressing  effects  upon  the  system.  Therefore  the 
first  rule  to  be  laid  down  in  the  treatment  of  syphilis  is  that  the 
hygiene,  regimen,  and  surroundings  of  the  patient  shall  be  made 
as  nearly  as  possible  perfect.  The  diet  must  be  simple,  ample,  and 
nourishing,  and  the  patient's  habits  as  to  eating,  drinking,  and 
sleeping  should  be  regular  and  systematic.  All  health-giving  sources 
of  recreation  and  exercise  should  be  made  use  of,  and  every  attention 
should  be  given  to  maintaining  the  health  and  vitality  of  the  patient  at 
as  high  a  plane  as  possible.  Therefore  patients  must  be  warned 
against  overtaxing  themselves  physically  or  mentally,  or  in  any  way 
putting  themselves  on  a  strain.  The  physician  should  always  be  watch- 
ful, particularly  in  the  treatment  of  patients  of  the  higher  classes,  about 
the  mental  wear  and  tear  to  which  so  many  are  liable.  In  such  cases 
syphilis  is  very  prone  to  produce  cerebral  and  mental  disturbances. 

While,  in  general,  abstinence  from  alcoholic  drinks  is  to  be  recom- 
mended for  syphilitic  patients,  it  is  always  well  to  exercise  wholesome 
common  sense  in  dealing  with  this  question.  Many  authors  go  to  an 
extreme  in  claiming  that  syphilitics  should  become  total  abstainers. 
The  ordeal  of  the  syphilitic  is  not  as  a  rule  a  very  happy  one,  and  the  less 
we  surround  him  with  irritating  restrictions  the  more  docile  will  he  be  in 
the  long  run  in  following  treatment.  Therefore  I  think  that  a  man 
who  by  habit  partakes  moderately  of  claret  or  burgundy  or  other  mild 
stimulant  at  his  chief  meal,  and  who  enjoys  it  and  is  seemingly  none 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.     673 

the  worse  for  it,  should  not  generally  be  deprived  of  it.  Then,  again, 
there  are  patients  who  partake  in  moderation  of  ale  and  beer,  and  who 
are  to  their  thinking  benefited  thereby.  Provided  these  stimulants  do 
not  disorder  the  stomach,  they  can  hardly  be  called  deleterious;  there- 
fore their  use  should  not  be  abruptly  interdicted.  On  the  other  hand, 
indulgence  in  strong  alcoholic  drinks  and  champagnes  must  be  per- 
emptorily stopped.  Nothing  is  more  galling  to  patients,  according  to 
my  experience,  than  a  treadmill  treatment  which  surrounds  them  with 
all  sorts  of  restrictions  and  imposes  upon  them  blue-law  abstinence. 
The  plan  which  works  best  in  the  long  run  in  handling  syphilitics  is 
that  which,  compatible  with  their  well-being,  gives  them  most  latitude 
and  revolutionizes  their  habits  and  modes  of  life  as  little  as  possible. 
To  sum  up,  alcohol  should  only  be  used  by  syphilitic  patients  in  great 
moderation  and  under  conditions  which  tend  to  improve  their  strength 
and  digestion. 

It  is  almost  unnecessary  to  say  that  excessive  sexual  indulgence  are 
depressing  and  exhausting  and  that  they  are  to  be  avoided.  Very 
many  cases  of  cerebral  and  nervous  syphilis  have  their  origin  in  sex- 
ual excess,  and  many  men  have  become  infirm  or  have  perished  from 
such  overindulgence  while  suffering  from  syphilis.  As  to  tobacco, 
we  can  hardly  speak  with  the  same  latitude  and  tolerance  as  we  can  of 
alcohol  in  syphilis.  Smoking  and  chewing,  even  in  mild  indulgence, 
are  so  prone  to  induce  irritation  and  inflammation  of  the  mouth  and 
throat,  which  it  is  so  vitally  necessary  to  keep  in  a  high  state  of  health, 
that  we  are  forced,  as  a  rule,  absolutely  to  prohibit  them.  It  requires, 
very  often,  considerable  moral  courage  to  deny  the  touching  appeal  of 
a  patient  to  be  allowed  one  or  two  cigars  a  day,  but  we  must  in  general 
stand  firm.  Still,  there  are  cases,  happily  for  them,  in  which,  despite 
syphilis  and  its  treatment,  irritation  of  the  mouth  and  throat  is  not 
produced,  and  such  patients  may  perhaps,  under  observation,  indulge 
their  favorite  habit.  Wherever  the  use  of  tobacco  produces  even  mild 
hyperaemia  of  the  mouth  and  throat  it  should  be  strictly  forbidden. 

All  functional  derangements  or  affections  of  internal  organs — stom- 
ach, intestines,  liver,  spleen,  kidneys,  etc. — should  be  carefully  attended 
to.  Patients  prone  to  pulmonary  affections,  and  those  having  a  ten- 
dency to  rheumatism  and  gout,  should  be  warned  in  advance  to  observe 
great  care  in  the  avoidance  of  the  causes  which  are  liable  to  light 
up  or  develop  these  dormant  tendencies.  In  like  manner,  neuropathic 
subjects,  and  those  suffering  from  any  hereditary  or  acquired  cerebral 
or  nervous  trouble,  should  be  made  carefully  but  impressively  to  under- 
stand that  the  nervous  system  is  their  weak  part,  and  that  while  they 
are  in  the  grip  of  syphilis  they  must  be  more  than  ordinarily  careful 
not  to  overtax  it  nor  to  abuse  it. 
43 


674      THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS. 

It  is  very  important  that  the  changes  of  the  seasons  and  weather 
should  be  met  with  appropriate  clothing,  and  that  the  utmost  precau- 
tion should  be  taken  against  catching  cold. 

While  the  physician  should  thus  impress  the  patient  with  the  gravity 
of  his  condition,  he  should  also  constantly  hold  out  to  him  that 
most  consoling  hope,  that  he  will,  in  all  probability,  be  free  from 
his  disease.  While  some  patients  are  calm  and  sensible,  and  others 
light-hearted  and  indifferent  to  their  physical  condition,  others,  again — 
happily  not  many — show  a  tendency  to  worry,  fret,  and  solicitude,  or 
even  to  a  depression  of  spirits  and  melancholy  which  is  termed  syphilo- 
phobia — a  most  distressing  state  of  mind  both  for  the  patient  and  his 
physician.  Such  cases  should  be  treated  with  constant  encouragement 
and  kindness  mingled  with  firmness ;  their  doubts  should  be  dispelled, 
their  fears  should  be  allayed,  and  bright  hopes  should  be  held  out  to 
them.  By  such  a  course  many  a  rough  spot  will  be  made  smooth,  and 
many  a  man  will  be  auspiciously  brought  through  his  syphilis  who 
otherwise  would  have  faltered  or  have  fallen  by  the  wayside. 

With  the  onset  of  the  generalized  manifestations  of  syphilis  at  the 
beginning  of  the  secondary  period  the  regular  methodical  treatment 
should  be  commenced.  At  this  time  and  at  short  intervals  thereafter  the 
patient  should  be  carefully  examined  as  to  the  condition  of  his  skin  and 
its  appendages,  of  his  mouth  and  throat,  and  lymphatic  system  gener- 
ally. Taking  for  an  example  a  case  of  roseola  with  its  usual  concom- 
itants of  slight  fever,  malaise,  and  perhaps  nocturnal  headaches  or 
rheumatoid  pains,  we  should  immediately  put  the  patient  upon  treat- 
ment by  the  mouth.  Later  on  the  inunction  method  may  be  em- 
ployed, but  as  a  rule  pills  are  quite  effective,  particularly  in  the  very 
early  secondary  stage.  While  intelligent  patients  will  usually  submit 
willingly  to  inunction  treatment  later  on,  its  adoption  at  the  very 
outset  is  liable  to  be  irksome,  and  to  give  them  the  idea  that  they 
have  a  very  trying  and  unpleasant  ordeal  before  them.  Though  many 
preparations  of  mercury  are  employed,  my  preference  is  for  the  proto- 
iodide,  thymoloacetate,  and  tannate  when  the  drug  is  given  in  pill- 
form.  Calomel  and  blue  pill  are  usually  not  satisfactory  agents.  Cal- 
omel is  very  liable  to  salivate  promptly,  and  its  action  is  far  from  cer- 
tain ;  and  as  to  blue  pill,  it  may  be  said  that  when  given  in  small  doses 
its  antisyphilitic  effect  is  very  feeble,  though  it  may  act  upon  the  liver, 
and  when  it  is  given  in  sufficient  quantity  one  never  knows  how  soon 
severe  salivation  may  be  induced.  Bichloride  of  mercury  very  com- 
monly produces  pain  in  the  chest  and  bowels  and  gastro-intestinal  irri- 
tation. Then,  again,  its  action  cannot  be  relied  upon,  for  in  small  doses 
by  the  stomach  it  does  little  if  any  good,  and  in  large  doses  it  is  very 
irritating.     Its    action   when  used   hypodermically    is,    however,    very 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.    675 

efficient  and  satisfactory,  and  its  local  action  in  the  form  of  lotions  and 
ointments  is  very  prompt  and  beneficial.  Within  recent  years  the  car- 
bolate,  salicylate,  alanilate,  and  other  preparations  of  mercury  have 
been  vaunted  as  possessing  marked  potentiality,  but  when  put  to  the 
test  they  are  found  to  possess  no  advantage  over  the  drugs  I  have 
named. 

Since  every  case  of  syphilis  is  a  law  unto  itself  as  to  the  amount 
of  mercury  which  will  be  required  for  its  cure,  we  can  only  state  the 
doses  approximately.  For  an  adult,  male  or  female,  a  quarter  or  a 
third  of  a  grain  of  the  protoiodide  may  be  given  at  a  dose,  of  which 
three  a  day  will  be  sufficient.  Very  large  and  robust  persons  may 
require  one-half  of  a  grain  at  a  dose.  These  are  always  suitable  doses  to 
begin  with,  and  by  them  the  tolerance  of  the  drug  may  be  gauged  and 
its  remedial  action  estimated. 

In  the  early  secondary  stage  there  are  certain  conditions  favorable  to 
an  active  treatment — namely,  a  system  virgin  to  mercurial  action  and  a 
greater  susceptibility  of  the  lesions  to  the  action  of  mercury.  This, 
then,  is  the  most  favorable  time  for  efficient  treatment,  and  it  is  the 
most  critical  one  in  the  life  of  the  syphilitic,  for  if  the  disease  is 
actively  attacked  then  its  backbone  may  be  broken.  It  is  very  prob- 
able that  much  of  the  late  rebelliousness  and  malignity  of  syphilis  is- 
due  to  the  fact  that  the  newly  formed  infecting  granulation-cells  and 
the  concomitant  subacute  inflammation  induce  in  organs  and  tissues, 
particularly  delicate  ones,  structural  and  nutritive  changes  which  pre- 
dispose  them  to  subsequent  low  grades  of  inflammation  and  cell- 
increase  ;  besides,  to  a  repetition  of  the  essential  syphilitic  process. 
Therefore  every  effort  should  be  made  to  destroy  these  young  infectious 
cells,  and  to  remove  them  as  quickly  as  possible  from  the  parenchyma 
of  organs  and  tissues,  before  they  shall  have  had  time  to  induce  these 
subtle  and  dangerous  structural  changes.  In  proportion  as  a  system- 
atic and  vigorous  mercurial  course  is  entered  upon  late,  so  it  is  less 
effectual  in  its  action.  There  is  no  doubt  whatever  in  my  mind  that  a 
mercurial  treatment  covering  the  first  six  months  of  the  disease  is 
far  more  salutary  and  effective  than  a  course  extending  over  a  year  or 
more  instituted  later  on. 

It  is  important,  therefore,  that  the  initial  course  should  be  active 
and  prolonged,  and  in  attaining  this  end  the  case  must  be  carefully 
handled  and  watched.  As  a  rule,  the  physician  can  form  a  correct 
estimate  as  to  the  probable  effect  of  mercury  upon  his  patient  within  a 
week  or  ten  days.  In  most  cases  the  dose  of  the  protoiodide  may  be 
increased  within  a  few  days  to  one  grain  or  one  grain  and  a  half,  and 
even  to  a  larger  quantity.  It  is  rarely  necessary  to  give  more  than 
three  grains  of  the  potoiodide  in  a  day,  and  most  cases  will  do  well  with 


676     THE   GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS. 

about  two  grains,  or  even  less.  The  tannate  of  mercury  is  a  very 
-active  drug,  which,  from  a  large  experience,  I  have  come  to  place  much 
confidence  in.  It  is  not  as  mild  as  has  been  claimed,  and  cannot  (as 
has  been  implied)  be  used  with  impunity.  In  some  cases  it  causes 
gastro-intestinal  irritation  and  severe  salivation.  Its  initial  dose  is  half 
a  grain  taken  three  times  a  day. 

In  combination  with  the  mercurial  preparation  we  may  employ  a 
ferruginous  or  bitter  tonic,  and  as  an  adjuvant  we  may  add  a  sedative 
agent  to  calm  the  intestinal  canal.  I  think  a  note  of  warning  should 
be  raised  against  the  combination  of  preparations  of  opium  in  antisyph- 
ilitic  remedies.  There  is  really  no  need  for  them,  and  much  harm  may 
be  done  by  their  continued  use  in  producing  an  habituation  to  the  drug, 
with  all  its  deleterious  effects  upon  the  nervous  system,  the  digestive 
organs,  and  the  tissues  generally.  We  can  never  determine  the  exact 
condition  of  a  patient  under  mercurial  treatment  who  is  also  under  the 
influence  of  opium.  As  a  general  rule,  in  stomach  ingestion  mercury, 
if  carefully  given,  causes  little  trouble.  It  may  produce  diarrhoea  and 
colicky  pains  for  a  day  or  two,  which  a  little  essence  of  ginger  or  pep- 
permint will  relieve,  or  it  may  be  necessary  to  omit  one  or  two  more 
doses.  In  general,  if  patients  are  careful  about  their  food  and  do  not 
take  too  much  fluid  into  their  stomachs,  the  mercurial  will  after  the  first 
disturbance  cause  no  irritation. 

Citrate  of  iron  and  quinine  as  a  tonic,  and  extract  of  hyoscyamus  as 
a  sedative,  may  be  used  in  combination  with  the  protoiodide  in  pill- 
form.  In  a  general  way  the  indications  for  the  treatment  of  the  sec- 
ondary stage  of  syphilis,  in  the  first  six  months,  are  as  follows  :  to 
administer  mercury  by  the  mouth  at  once,  and  thus  continue  for  three 
or  four  weeks ;  then  either  gradually  or  abruptly  to  substitute  the 
inunction  method.  Having  found  that  inunctions  produce  a  good  effect, 
they  should  be  continued  according  to  the  indications  of  the  case.  Some 
patients  can  receive  Avith  benefit  and  no  discomfort  twenty  or  thirty  con- 
secutive daily  inunctions;  others  can  stand  only  one  such  rubbing  every 
second  or  third  day.  In  the  event  of  the  necessity  of  using  inunctions 
less  frequently  than  every  day  or  every  second  day,  it  is  well  to  admin- 
ister mercury  by  the  mouth  in  the  intervals.  In  many  cases,  even  in 
early  syphilis,  it  is  often  wise  to  discontinue  either  the  pills  or  the 
inunctions  for  one  or  more  weeks,  during  which  time  the  combinations 
of  a  mercurial  salt  and  iodide  of  potassium  known  as  the  mixed  treat- 
ment may  be  administered.     (See  page  680.) 

The  iodide  of  potassium  is  certainly  very  efficient  in  ridding  the 
system  of  the  toxins  produced  by  syphilis  ;  hence  its  use  in  alternation 
with  active  internal  mercurialization  in  the  first  six  months  of  syphilis 
is  urgently  called  for. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.     677 

In  some  cases  iodide  of  potassium  becomes  the  mainstay  of  treatment. 
in  early  syphilis.  These  cases  are  those  in  which  there  is  early  develop- 
ment of  cerebral  symptoms — severe  headaches,  epilepsy,  hemiplegia, 
aphasia,  and  dementia.  The  early  supervention  of  osseous  and  articular 
lesions,  the  occurrence  of  epididymitis  or  orchitis,  precocious  affections 
of  the  ear  and  eye,  and  swelling  of  the  spleen  and  liver  should  all  be 
combated  with  a  combined  iodide  and  mercurial  treatment.  In  like 
manner,  the  precocious  development  of  cutaneous  gummata  and  gum- 
matous infiltration  into  mucous  membranes  (particularly  of  the  mouth 
and  pharynx)  indicates  the  necessity  of  local  mercurialization  when  prac- 
ticable and  the  internal  use  of  the  iodide  of  potassium.  In  some  cases 
of  rheumatoid  pains  and  early  rheumatism  it  may  be  necessary  to  use 
the  iodide  quite  early. 

The  criteria  which  indicate  that  treatment  is  efficient  should  be 
carefully  studied.  If  the  patient  looks  and  feels  well,  sleeps  soundly, 
eats  heartily,  holds  his  accustomed  weight,  and  is  mentally  and  phys- 
ically in  a  satisfactory  condition,  there  is  strong  evidence  that  he  is 
being  benefited.  But  we  must  further  assure  ourselves  that  the  lesions 
are  being  acted  upon.  The  indurated  nodule  must  have  wholly  disap- 
peared, the  lymphatic  engorgement  must  show  evident  signs  of  involu- 
tion, and  the  rash  must  have  faded.  The  throat  and  mouth  must  be 
inspected  very  often,  and  any  red  patches  or  ulcerative  lesions  should  be 
actively  treated.  In  like  manner  papular  and  pustular  lesions  in  hairy 
parts  should  be  treated  locally.  Painful  spots  and  swellings  upon  bones 
or  near  or  at  joints,  thickening  of  the  fasciae  and  subcutaneous  connective 
tissues,  should  receive  regional  treatment.  In  like  manner,  in  cases 
of  headaches,  neuralgias,  rheumatoid  pains  of  muscles,  eye  and  ear  affec- 
tions, affections  of  the  hairs  and  nails,  the  mercurial  medication  should 
be  brought  as  near  as  possible  to  the  morbid  area.  It  is  also  advisable 
to  watch  for  and  act  promptly  upon  red  scaling  patches  and  papules 
seated  upon  the  palms  and  the  soles,  since  they  are  very  persistent. 
Any  swellings  and  hyperplasias  about  the  mouth  or  face,  vulva,  anus, 
and  scrotum  should  receive  suitable  local  treatment. 

While  in  general  the  initial  course  of  treatment,  occupying  six 
months  if  possible,  should  consist  mainly  of  medication  by  the  mouth 
or  by  inunction,  the  physician  should  be  watchful  of  all  complications 
and  developments,  should  be  on  the  lookout  for  all  drawbacks  and 
dangers,  and  should  be  ever  prompt  and  ready  with  such  modifications 
of  treatment,  such  expedients,  and  such  reserve  measures  of  aid  as  the 
case  may  demand. 

In  most  cases  a  continuous  mercurial  course  of  six  months  may  be 
pursued  without  experiencing  any  serious  drawbacks  if  the  patient  be 
properly  watched.     There  may  be  periods  of  a  few  days  in  which  it 


678     THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS. 

is  necessary  to  suspend  medicine  and  either  leave  the  stomach  at  rest 
or  give  tonics.  But,  as  a  rule,  this  early  period  offers  a  golden 
opportunity.  It  is  our  duty  to  avail  ourselves  of  the  then  existing 
favorable  condition  of  the  system  to  assimilate  mercury.  In  rare 
cases  mercury  taken  by  the  stomach  acts  as  a  general  depressant  and 
the  patient's  nutrition  is  impaired.  These  grave  drawbacks  and 
seeming  contraindications  may  be  promptly  dispelled  by  the  employ- 
ment of  hypodermic  injections  of  the  bichloride  of  mercury.  In  such 
cases  it  is  well  to  begin  with  a  moderate  dose,  and  then  work  upward 
as  fast  as  we  can. 

While  a  patient  is  undergoing  this  mercurial  course  he  should  have 
one  or  two  baths  each  week  on  going  to  bed,  in  order  to  produce 
diaphoresis.  When  practicable  he  should  take  Turkish  baths,  without 
the  cold  plunge,  and  after  them  should  be  made  to  sweat  freely.  At 
the  seaside  cold  salt-water  baths  are  very  beneficial,  and  an  occasional 
hot  sea-water  bath,  followed  by  packing  and  a  sweat,  is  a  valuable 
adjuvant  to  mercurial  treatment. 

In  cases,  particularly  uncomplicated  ones,  well  treated  from  the 
beginning  there  are  usually  no  perceptible  secondary  or  tertiary  stages. 
The  secondary  stage  is  entered  upon,  the  disease  is  systematically  at- 
tacked, and,  excepting,  perhaps,  a  few  ephemeral  and  trifling  manifesta- 
tions upon  the  skin  or  mucous  membrane  (and  they  are  largely  pro- 
duced by  extraneous  irritation,  friction,  coaptation  of  parts,  want  of 
cleanliness,  smoking,  etc.),  he  or  she  sees  no  further  development.  Still, 
some  cases  are  rebellious,  and  tax  our  resources  and  patience,  and  some 
— happily  few — go  badly  from  the  start. 

Having  administered  efficient  medication,  with  few  and  short  in- 
terruptions, for  about  six  months,  it  is  safe  to  say  that  in  most  cases, 
particularly  uncomplicated  ones,  the  patient  will  be  well  on  his  way  to 
recovery. 

If  the  condition  of  the  patient  is  satisfactory,  as  shown  by  the 
absence  of  all  lesions,  by  almost  entire  subsidence  of  the  lymphatic 
ganglia,  by  a  good  condition  of  his  nutrition  and  strength,  and  by  the 
absence  of  symptoms  pointing  to  nervous  depression  and  debility,  at  the 
end  of  six  months  he  may  have  a  rest,  the  moral  effect  of  which  will  be 
very  salutary.  Patients  very  often  weary  of  the  long-continued  dosing, 
and  in  the  interval  of  repose  they  cease  to  consider  themselves  sick,  and 
have  an  opportunity  to  judge  of  their  condition  when  they  are  free  from 
the  effect  of  drugs.  Therefore,  a  month's  cessation  of  medication  should 
be  granted,  and,  if  possible,  the  patient  should  go  to  the  seaside  or  the 
mountains  and  have  an  entire  change  of  air  and  scene.  It  is  not 
uncommon,  however,  to  see  patients  who  do  not  desire  a  period  of 
freedom  from  medication,  but  persist  in  carrying  on  the  treatment. 


THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS.     679 

On  resuming  the  treatment  my  preference  is  to  begin  a  systematic 
inunction  course.  In  cases  in  which  this  is  impracticable  or  for  any 
reason  contraindicated,  I  have  come  to  look  with  much  favor  upon 
a  combination  of  a  full  dose  of  mercury  with  a  small  dose  of  the 
iodide  of  potassium.  The  following  prescription  will  illustrate  my 
meaning: : 


3^.  Hydrarg.  biniodidi,  gr.  ij  to  iv ; 

Potassii  iodidi,  3ss ; 

Tr.  cinchona?  comp.,  siiiss  ; 

Aquae,  5ss. — M. 

Sig.  One  teaspoonful  three  times  a  day,  an  hour  after  eating,  in  a 
wine-glassful  of  water. 

In  this  prescription  the  mercurial  is  the  efficient  agent,  and  the 
iodide  simply  serves  the  purpose  of  rendering  it  soluble.  When 
there  is  debility  the  fluid  extract  of  coca  may  be  added.  From  a 
wide  experience  I  have  convinced  myself  that  this  mixture  of  mercurv 
and  iodide  of  potassium  is  remarkably  efficient  and  beneficial  after 
the  sixth  or  eighth  month  of  the  secondary  period,  particularly  in 
cases  which  have  been  previously  subjected  to  treatment.  This  combi- 
nation is  usually  well  borne  by  the  stomach  even  when  the  maximum 
quantity  of  the  biniodide  is  ordered.  But  great  care  must  be  observed 
in  its  administration,  and  if  gastro-intestinal  irritation  is  produced  the 
dose  must  be  made  smaller ;  and  if  a  depressing  effect  upon  the  general 
nutrition  or  upon  the  nervous  system  is  observed,  the  remedy  must  for 
a  time  be  suspended.  In  these  cases  rest  and  change  of  air  and  scene 
are  very  beneficial. 

The  second  course  of  treatment  may  be  kept  up,  with  or  without 
slight  interruptions,  for  three  or  four  months,  or  even  longer  if  the 
patient  shows  no  signs  of  deterioration  of  health  referable  to  the  treat- 
ment. During  this  second  course  inunctions  also  may  be  used,  with 
proper  intervals  of  rest,  or  fumigations  may  be  employed,  according 
to  the  indications  of  the  case.  There  may  be  reasons  which  render 
a  course  of  hypodermic  injections  of  sublimate  preferable.  In  this 
way  the  first  year  passes,  during  which  the  patient  will  have  been 
under  dosage  treatment  nine  or  ten  months. 

Toward  the  end  of  the  first  year,  if  not  before,  combinations  of 
mercury  with  iodide  of  potassium  in  quite  large  doses  are  very  often 
beneficial.  The  use  of  these  combinations  is  generally  known  as 
the  "  mixed  treatment."  The  following  prescriptions  are  of  much 
value  : 


680     THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS. 

Iy.  Hydrarg.  biniodidi,  gr.  j-ij  • 

Potassii  iodidi,  oss-sj  ; 

Syr.  aurantii  cort.,  giij  ; 

Aquas,  SJ. — M. 

Sig.  One  teaspoonful  three  times  a  day,  an  hour  after  eating,  in  a 
wine-glassful  of  water. 

]^.  Hydrarg.  bichloridi,  gr.  j-ij-iij  ; 

Potassii  iodidi,  3ss-3j-siss ; 

Tr.  cinchonas  comp.,  3iiss  ; 

Aquas,  3*ss. — M. 

To  be  taken  in  the  same  manner  as  the  foregoing. 

The  combination  of  the  inunction-treatment  with  iodide  of  potassium 
taken  internally  is  often  very  beneficial  indeed,  and  should  be  employed 
in  late  secondary  and  tertiary  lesions,  particularly  when  localized  to 
certain  regions,  which  should  be  acted  upon  directly  by  the  mercurial 
ointment.  The  simultaneous  employment  of  hypodermic  injections  of 
a  mercurial  salt  with  the  ingestion  of  iodide  of  potassium  is  sometimes 
productive  of  prompt  and  marked  benefit.  As  a  rule,  the  foregoing 
combinations  are  very  useful  toward  the  end  of  the  first  year  of  syph- 
ilis, but  in  many  cases  having  an  unusual  course,  and  chiefly  those 
in  which  late  lesions  appear  precociously,  it  may  be  necessary  to  resort 
to  them  at  an  earlier  date.  It  is  always  necessary  to  watch  the  con- 
dition of  the  stomach  when  the  mixed  treatment  is  being  employed  or 
when  large  doses  of  the  iodide  are  administered.  As  soon  as  signs  of 
gastric  irritation  show  themselves  the  remedy  must  be  suspended,  and, 
if  necessary,  symptomatic  treatment  should  be  adopted.  The  iodide 
alone  or  in  combination  may  act  as  a  depressant  upon  nutrition  and  upon 
the  nervous  system.  In  these  cases  it  may  be  necessary  to  reduce  the 
dose  or  to  intermit  the  treatment. 

In  the  carrying  out  of  the  methodical  general  treatment  of  syphilis 
in  the  second  year  of  the  disease  the  periods  of  dosage  may,  on  an 
average,  be  stated  at  two  to  three  months,  with  intervals  of  rest  of  a 
month  or  six  weeks.  In  this  way  about  eight  months  are  required  for 
actual  medication.  In  most  cases  at  the  end  of  the  second  year  of 
thorough  treatment  patients  may  be  pronounced  cured,  provided  they 
have  not  for  many  months  shown  evidence  of  the  disease,  that  their 
lymphatic  system  appears  healthy,  and  their  general  health  and  nutri- 
tion are  good.  Though  there  is  a  disposition  on  the  part  of  those  who 
rely  chiefly  on  mouth-medication  to  extend  the  treatment  of  syphilis 
indefinitely,  I  see  no  reason  whatever  for  altering  the  opinion  that  I 
have  many  time  stated,  that  if  an   energetic   and  thorough   treatment 


THE  GENERAL   METHODICAL   TREATMENT  OF  SYPHILIS.     681 

(such  as  I  have  sketched)  be  followed  for  two  years  or  two  years  and  a 
half,  the  patient  will  be  cured,  as  shown  by  the  enjoyment  of  good 
health,  by  freedom  from  syphilitic  manifestations,  and  by  his  or  her 
ability  to  procreate  healthy  children.  In  some  cases  this  auspicious 
result  may  be  the  outcome  of  treatment  by  pills,  but  in  most  it  will  only 
be  attained  by  the  zealous  and  intelligent  employment  of  inunctions, 
supplemented  by  other  methods  and  by  the  use  of  the  iodide. 

For  some  cases  of  late  secondary  and  early  tertiary  lesions  of  the 
skin,  particularly  when  attended  with  scaling,  Donovan's  solution — 
liquor  arsenii  et  hydrargyri  iodidi — is  sometimes  beneficial.  The  dose 
is  5  to  10  drops,  given  in  a  bitter  tincture  and  well  diluted  with  water, 
an  hour  after  eating. 

Decoctions  and  infusions  of  such  vegetables  as  sarsaparilla,  yellow 
dock,  saponaria,  stillingia,  and  others  have  long  been  held  in  high  esteem 
by  the  laity  for  the  treatment  of  syphilis.  They  have  absolutely  no 
antisyphilitic  influence,  and  if  they  are  beneficial  at  all,  the  effect  is  due 
to  their  influence  as  tonics,  stomachics,  diuretics,  or  diaphoretics.  They 
may  be  beneficial  as  adjuvants  to  mercury  and  iodide  of  potassium. 

In  Germany  and  in  America  Zittman's  decoction  is  used  in  old, 
obstinate  cases  of  syphilis  when  the  usual  remedies  are  badly  if  at 
all  borne,  and  when  the  physician  is  at  his  wits'  end  to  know  what  to 
do.  In  many  very  unpromising  cases  I  have  seen  beneficial,  and  even 
striking,  results  ;  hence  this  remedy  should  be  kept  in  mind. 

As  an  adjuvant  in  the  treatment  of  syphilis  the  fluid  extract  of  coca 
is  a  very  valuable  agent.  It  is  in  no  sense  a  specific,  and  its  beneficial 
action  consists  in  its  marked  tonic  effect  upon  the  heart,  capillaries,  and 
nervous  system,  and  upon  nutrition  in  general.  In  ansemia  and  cachexia 
and  in  the  adynamic  condition  occasionally  induced  by  mercury  and 
iodide  of  potassium  it  sometimes  works  wonders.  In  some  cases  I  have 
seen  it  induce  a  condition  of  receptivity  by  which  mercury,  which  at  first 
was  badly  borne,  became  tolerated  and  curative.  In  malignant  preco- 
cious syphilis  it  acts  well  by  improving  the  general  nutrition.  It  is 
very  often  beneficial  to  patients  addicted  to  alcoholics,  and  it  may 
then  take  the  place  of  those  stimulants. 

Preparations  of  iron,  quinine,  and  strychnine  are  also  very  beneficial 
adjuvants. 

Thyroid  extract  in  full  doses  has  been  reported  as  being  very  bene- 
ficial in  a  number  of  cases  of  tertiary  syphilis  in  which  there  was  great 
cachexia.  Hvpodermic  injections  of  the  blood-serum  of  animals  and 
of  the  serum  of  syphilitics  have  been  used  in  the  treatment  of  secondary 
and  tertiary  syphilis,  but  in  all  instances  they  utterly  failed. 

It  may  be  stated  as  a  broad  general  rule  that  when  cases  come  under 
treatment  after  the  disease  has  existed  for  several   months,  they  should 


682     THE   GENERAL   METHODICAL   TREATMENT  OF  SYPHILIS. 

be  placed  at  once  upon  the  inunction  method.  This  course  is  particu- 
larly to  be  followed  when  the  patient  presents  a  more  or  less  general 
eruption.  In  these  cases  we  very  often  cannot  bring  sufficient  mercury 
to  act  upon  the  surface  of  the  skin  through  the  medium  of  the  blood- 
circulation,  and  it  is  a  waste  of  time  and  effort  to  make  the  patient 
swallow  pills.  In  all  cases  in  which  treatment  is  begun  rather  late 
the  physician  should  be  particularly  careful  to  try,  as  far  as  possible,  to 
exert  a  prompt  and  efficient  influence  upon  the  disease,  and  to  keep  up 
the  treatment  for  (as  a  rule)  six  months  without  much  interruption.  In 
this  way  he  may  be  able  to  make  up  for  lost  time,  which  is  so  essential. 
In  these  untreated  cases  mercurial  fumigations,  hypodermic  injections, 
and  the  combined  use  of  mercurials  with  iodide  of  potassium  are  often 
productive  of  marked  benefit. 

Late  secondary  and  tertiary  lesions  of  the  skin  and  mucous  mem- 
brane, affections  of  the  bones,  periosteum,  and  joints,  late-appearing 
affections  of  the  eye,  ear,  and  cerebrospinal  system,  of  the  viscera,  and 
of  the  testes  and  penis,  require  a  combination  or  mixed  treatment.  In 
many  cases  it  is  necessary  to  increase  the  dose  of  the  iodide  far  beyond 
those  mentioned,  sometimes  to  the  extent  of  one  or  two  ounces  a  day. 

It  must  be  remembered  that  the  arbitrary  rule  laid  down  by  some 
authors,  that  early  in  syphilis  mercury  is  indicated,  and  that  later  on 
the  iodide  alone  should  be  given,  is  not,  in  general,  a  good  one.  Many 
cases  of  tertiary  syphilis  have  remained  unaffected  by  the  use  of  the 
iodide  alone,  and  have  promptly  improved  and  soon  recovered  after  mer- 
cury also  was  given.  The  use  of  mercury,  therefore,  should  not  be 
limited  to  the  secondary  stage,  but  should  also  be  employed  in  tertiary 
syphilis,  either  by  inunction  or  hypodermic  injection  or  fumigations, 
combined  with  the  iodide  given  internally. 

It  will  be  generally  found  that  patients  who  have  followed  a  sys- 
tematic and  thorough  course  of  treatment  during  the  first  year  rarely 
present  tertiary  lesions.  The  cases  which  present  these  graver  dis- 
orders are  usually  those  which  have  been  the  subject  of  complica- 
tions in  the  secondary  stage,  or  those  in  which  an  early  efficient  treat- 
ment has  not  been  followed  or  has  been  indifferently  followed.  Patients 
presenting  tertiary  lesions  should  be  actively  treated,  but  at  the  same 
time  close  attention  must  be  paid  to  their  general  condition,  for  in 
many  of  them  nutrition  is  impaired  and  a  condition  of  cachexia  exists. 

It  is  necessary  now  to  consider  the  facts  concerning  the  mercurial 
inunction  method,  mercurial  fumigations,  hypodermic  mercurial  in- 
jections, and  thermal  baths. 


THE  INUNCTION  METHOD.  683 

THE    INUNCTION  METHOD. 

Most  patients  will  submit  to  this  method  when  its  great  advantages 
are  clearly  presented  to  them.  During  this  treatment  the  patient  must 
observe  good  hygienic  regime  ;  he  should  avoid  taking  cold  and  exer- 
cise care  as  to  his  diet. 

The  most  reliable  and  efficient  preparation  of  mercury  for  the  inunc- 
tion-cure is  the  officinal  mercurial  or  blue  ointment — unguentum  hydrar- 
gyri — of  a  strength  of  50  per  cent.,  as  a  rule.  It  is  most  important 
that  this  preparation  shall  be  well  made  and  perfectly  fresh.  It  is 
not  sufficient  simply  to  order  the  blue  ointment,  but  the  patient  should 
be  impressed  with  the  necessity  of  obtaining  a  perfectly  pure  prepara- 
tion, and  should  be  particularly  instructed  to  purchase  it  of  only  re- 
liable apothecaries  who  frequently  renew  their  stock.  Many  instances 
of  irritation  of  the  skin  are  due  solely  to  the  rancidity  of  the  ointment 
rubbed  in.  The  matter  of  the  dose  should  be  carefully  looked  after,  so 
that  absolute  precision  is  obtained. 

For  general  practice  the  average  dose  of  blue  ointment  may  be  stated 
at  from  45  to  60  grains,  a  larger  dose  being  used  upon  robust  and  wrell- 
developed  patients,  and  a  smaller  one  upon  those  of  thin  and  flabby 
structure.  The  early  rubbings  are  largely  tentative,  with  a  view  of 
gauging  the  patient  and  the  dose.  The  inunction-treatment  should 
never  be  begun  in  a  careless  manner.  The  case  being  a  suitable  one, 
two  or  three  frictions  of  30  grains  each  may  be  tried  and  the  effect 
watched.  Some  patients  bear  these  inunctions  when  of  generous  quantity 
with  remarkable  tolerance  for  very  long  periods ;  others,  again,  show 
evidence  contraindicating  their  use  after  three  to  six  rubbings.  There- 
fore, the  physician  should  have  his  patient  well  in  hand,  and  watch 
him  very  carefully  every  day  or  two  until  he  has  been  under  the 
treatment  for  at  least  two  or  three  weeks.  As  the  frictions  are  given 
and  benefit  is  evident,  the  dose  may  be  increased  to  60  or  90  grains 
of  the  ointment ;  and  in  general,  for  regular  routine  treatment  this 
quantity  will  be  found  ample,  but  in  emergencies  and  exigencies  a 
larger  quantity  will  be  required.  While  the  patient  is  under  this  treat- 
ment (the  general  and  special  condition  being  favorable)  the  phvsician 
must  watch  and  question  him,  to  learn  that  he  feels  stronger  and  even 
gains  weight,  which  is  very  common  when  this  treatment  is  beneficial, 
and  is  really  one  of  the  first  signs  of  improvement ;  that  his  strength  is 
satisfactory  ;  that  his  appetite  is  good  and  digestion  perfect ;  that  he 
has  no  elevations  or  oscillations  of  temperature  ;  that  he  sleeps  well 
at  night  and  awakes  refreshed  ;  and  that  he  is  not  troubled  with 
even  slight,  nervous  symptoms.  If,  in  short,  a  man  shows  signs  of 
doing  well,  and  has  no  mouth,  stomach,  or  intestinal  troubles,  and  it  is 


684     THE  GENERAL  METHODICAL    TREATMENT  OF  SYPHILIS. 

evident  that  his  general  condition  is  being  improved,  the  physician 
may  know  that  he  is  on  the  right  track,  and  should  go  ahead,  but 
should  always  be  on  the  lookout  for  the  mouth  and  the  gastro- 
intestinal tract.  When  mercury  is  thus  introduced  through  the  skin, 
it  is  thought  that  it  enters  not  by  the  lungs,  but  by  way  of  the  sweat, 
hair,  and  sebaceous  follicles,  into  the  lymph-spaces,  and  then  becomes 
albuminized  and  ready  for  absorption.  We  then  have  the  stomach  free 
for  food,  tonics,  or  the  iodide  of  potassium,  if  it  is  indicated.  Thus  we 
may  improve  digestion  and  nutrition  by  agents,  such  as  iron,  quinine, 
strychnine,  coca,  hypophosphites,  etc.  This  coincident  tonic  course  is 
often  very  beneficial  in  improving  the  condition  of  the  syphilitically 
affected  tissues,  and  in  rendering  them  more  amenable  to  the  specific 
action  of  the  mercury.  In  this  connection  it  is  to  be  prominently  re- 
membered that  a  decided  tonic  action  is  produced  by  generous,  nutritious 
diet,  which  does  so  much  to  engraft  upon  the  tissues  the  power  of  re- 
sistance to  the  syphilitic  poison. 

When  the  patient  undergoes  the  frictions  at  home  he  must  first  have 
a  local  or  general  bath.  Asa  rule  in  city  life,  the  inunctions  are  of  neces- 
sity taken  in  the  evening,  whereas  at  health  resorts  it  is  well  that  they 
should  be  taken  in  the  morning.  The  home  patient  may  take  a  bath 
at  a  temperature  of  96°  to  98°  F.,  after  which  he  should  be  well  rubbed 
with  a  towel.  When  possible,  in  warm  weather  one  or  two  Turkish 
baths  a  week  may  be  taken  in  alternation  with  the  regular  baths.  But 
of  these  baths  the  physician  must  be  very  watchful,  and  if  they  in  any 
way  tend  to  debilitate  the  patient,  who  under  the  circumstances  sleeps 
poorly  and  awakes  unrefreshed,  stiff,  and  weak,  they  should  be  discon- 
tinued. Under  these  circumstances,  and  when  it  is  impossible  to  have 
bathing  facilities,  the  part  to  be  anointed  should  be  carefully  washed  with 
warm  water  and  soap,  and  then  sponged  with  a  2  or  3  per  cent,  solu- 
tion of  carbolic  acid.  This  latter  application  should  also  always  be 
used  after  the  general  bath.  By  strict  attention  to  the  aseptic  condition 
of  the  skin  we  can  almost  always  avoid  dermal  inflammatory  compli- 
cations. When  it  is  urgently  necessary  to  treat  parts  covered  with  hair, 
they  may  be  clipped,  or  even  shaved,  and  then  thoroughly  washed  with 
the  carbolic  solution.  Upon  parts  sparsely  supplied  with  hairs  great 
care  should  be  taken  that  an  aseptic  condition  be  produced.  By 
the  observance  of  care  many  unpleasant  complications  may  be 
avoided. 

It  is  always  best  that  the  inunctions  should  be  made  by  a  profes- 
sional rubber  or  a  trained  nurse,  if  possible.  If,  owing  to  circum- 
stances, the  patient  must  be  his  own  rubber,  he  should  be  made  clearly 
to  understand  the  technic.  In  the  first  place,  the  physician  must  see 
that  the  dose  is  made  precise,  and  if  the  ointment  is  put  up  in  packets 


THE  INUNCTION  METHOD.  685 

of  oiled  paper  allowance  must  be  made  for  the  loss  occasioned  by  the 
adherence  of  some  of  the  ointment. 

The  ointment  should  be  divided  into  several  portions,  and  each  one 
should  be  firmly  rubbed  into  the  skin,  employing  the  two  palms  when 
the  anatomical  arrangement  of  the  parts  will  admit  of  it.  Combined 
with  the  friction,  a  moderate  amount  of  massage  may  be  practised.  In 
this  way  all  the  ointment  must  be  rubbed  in,  so  that  no  lumps  are  left ; 
the  surface  of  the  skin  will  then  look  as  if  it  had  been  lightly  pot- 
leaded.  As  a  general  rule,  from  twenty  to  thirty  minutes  are  necessary 
for  an  inunction.  After  this  operation  suitable  night-clothes  should  be 
put  on  to  protect  the  bed-linen,  and  the  patient  should  retire.  When 
the  preliminary  general  bath  cannot  be  taken,  it  is  well  to  let.  the  patient 
drink  directly  after  the  rubbing  a  pint  or  more  of  fresh  hot  milk, 
and  then  cover  himself  well  with  blankets  in  order  to  induce  perspira- 
tion. According  to  his  case  and  to  the  whim  of  the  patient,  hot  lemon- 
ade or  hot  tea  (and  in  some  cases  a  little  brandy,  whiskey,  or  gin  may 
be  added)  may  be  taken  to  produce  diaphoresis   after  the    inunction. 

It  is  well  to  divide  the  body  into  eleven  subdivisions,  each  of  which 
is  to  be  submitted  to  its  own  mercurial  friction.     They  are  as  follows  : 

1.  The  neck  and  head. 

2  and  3.  The  arms,  palms,  and  axillae. 

4  and  5.  The  legs  and  soles. 

6  and  7.  The  thighs,  with  groins  and  Scarpa's  triangle. 

8  and  9.  The  breast  and  abdomen. 

10  and  11.  The  back  from  the  root  of  the  neck  to  lower  part  of  the 
gluteal  region. 

In  non-hairy  persons  there  is  little  trouble  in  anointing  the  neck. 
In  those  whose  necks  are  densely  covered  with  hair  we  may  be  forced 
to  confine  the  inunctions  to  the  parts  not  covered.  In  urgent  cases  and 
where  the  lesions  are  copious  it  is  necessary  to  have  the  hair  clipped  or 
shaved.  If  there  are  scalp  lesions  or  any  in  the  beard,  an  ointment 
composed  of  white  precipitate  (30  grains)  and  vaseline  (1  ounce)  may  be 
used  freely.  In  this  case  it  may  be  well  to  make  the  regular  dose  of 
mercurial  ointment  used  elsewhere  on  the  neck  smaller.  Prior  to  rub- 
bing the  ointment  into  the  scalp  and  beard  shampoos  and  antiseptic 
lotions  should  be  used. 

It  is  important  that  the  whole  surface  of  the  arms  should  be  acted 
upon  in  a  vigorous  manner.  If  there  are  any  lesions  of  the  palms, 
these  parts  should  receive  careful  attention,  and  in  any  case  it  is  well 
to  anoint  them  several  times  during  the  treatment.  It  is  most  impor- 
tant to  bring  the  ointment  into  contact  with  the  contents  of  the  axillae  ; 
and  this  can  be  done  with  impunity,  provided  care  is  taken  that  the 
parts  are  rendered  aseptic. 


686     THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS. 

The  legs  and  the  soles  should  be  well  rubbed  with  both  hands,  and 
any  lesions  upon  the  latter  parts  should  receive  especial  attention.  In 
like  manner  the  thighs  should  be  treated,  and  the  groins  and  the  sur- 
face over  Scarpa's  triangle  should  be  firmly  rubbed  for  a  sufficient  time. 
If  the  ganglia  in  the  groins  are  much  swollen,  it  may  be  necessary 
to  apply  a  layer  of  mercurial  ointment  on  lint  or  one  of  the  mercurial 
plasters.     Care  need  not  be  taken  to  keep  the  ointment  from  the  scrotum. 

Sometimes  the  inunctions  produce  irritation  upon  the  breast  and 
abdomen,  and  the  method  is  pursued  with  difficulty.  Under  these  cir- 
cumstances all  means  toward  the  avoidance  of  dermatitis  and  follicular 
inflammation  should  be  adopted. 

Patients  rarely  have  any  difficulty  in  administering  to  themselves 
inunctions  upon  the  buttocks,  but  it  is  impossible  for  them  to  reach 
their  backs.  Therefore  it  is  necessary  to  get  outside  aid,  which  in  most 
cases  I  have  found  possible.  By  this  method  the  whole  body  is  treated 
in  eleven  seances.  In  many  cases,  when  we  use  from  45  to  60  grains 
of  the  ointment  for  each  rubbing,  we  can  give  the  whole  series  of  eleven 
on  successive  days.  But,  as  I  have  said  before,  we  can  never  be  posi- 
tive that  we  can  do  so  ;  therefore  the  patient  must  be  watched  and 
questioned  each  day  as  to  his  condition.  In  this  way  we  feel  our  way, 
and  continue  or  suspend  the  inunctions  as  the  indications  of  the  case 
teach  us. 

In  giving  a  regular  treatment  by  inunctions  it  is  well  to  omit  them 
for  a  few  days  according  to  the  indications,  and  then  to  go  over  the 
same  ground  again.  In  a  systematic  treatment  we  may  give  fifty  to 
eighty,  or  even  a  hundred,  inunctions  with  proper  intermissions,  and 
then  it  is  well  to  desist  for  a  short  or  long  time.  In  ordinary  cases, 
where  the  inunction  method  is  used  as  a  regular  mode  of  treatment,  it 
may  or  may  not  be  necessary  to  administer  the  iodide  of  potassium  at 
the  same  time.  In  most  cases  it  will  not  be  necessary  to  employ  a 
large  dose  of  this  salt.  But  in  old  and  untreated  cases  it  will  be  neces- 
sary to  use  stronger  doses  of  the  ointment,  perhaps  employ  them  more 
frequently,  and  combine  them  with  large  doses  of  the  iodide,  given 
internally. 

It  sometimes  happens  that  we  desire  to  keep  up  a  mild  mercurial 
action,  and  the  circumstances  of  the  patient  will  not  admit  of  the  em- 
ployment of  frictions.  In  these  cases  the  ointment  may  be  spread  upon 
a  canton-flannel  belt,  which  may  be  worn  around  the  body.  In  cases 
of  enlargement  of  the  spleen,  tenderness  over  the  liver,  with  or  without 
jaundice,  pain  in  the  chest  (pleuritic  or  resembling  angina  pectoris),  and 
in  swollen  and  painful  joints,  these  mercurial  bandages  may  be  employed 
with  much  benefit.  This  method  is  also  useful  in  the  treatment  of 
syphilitic  infants  and  children. 


MERCURIAL  FUMIGATION.  687 

Though  the  inunction  treatment  is  uniformly  potent  and  beneficial, 
it  has  its  drawbacks  and  complications.  These  are — 1,  dermatitis  and 
follicular  inflammation  ;  2,  stomatitis  and  salivation  ;  3,  digestive  dis- 
turbances and  intestinal  complications ;  4,  sleeplessness ;  5,  inanition 
and  exhaustion  ;  6,  tendency  to  congestion  of  the  head,  heart,  and 
lungs  ;  7,  tendency  to  fever  and  perspiration  ;  8,  pain  in  bones  and 
joints.  Though  this  list  looks  rather  formidable,  in  actual  practice 
the  cases  are  few  in  which  it  is  necessary  to  abandon  the  treatment  or  in 
which  modifications  and  expedients  fail  to  smooth  matters  over.  In 
some  cases  a  short  suspension  of  the  treatment  may  set  matters  right, 
while  in  others  a  temporary  diminution  of  the  quantity  of  the  ointment 
effects  the  same  purpose. 

It  sometimes  happens  that  a  patient  is  unable  to  employ  a  profes- 
sional rubber,  and  is  indisposed  to  the  physical  exertion  incident  to  the 
inunction-method.  In  these  circumstances  the  ointment  may  be  quite 
freely  spread  over  the  chest  and  shoulders  and  arms  and  there  left.  It 
is  claimed  that  the  heat  of  the  body  volatilizes  the  mercury,  and  that  it 
enters  the  system  through  the  lungs. 

MERCURIAL  FUMIGATION. 

The  mercurial  vapor-bath  is  a  method  of  treating  syphilis  which  is 
useful  in  very  many  cases  and  in  many  conditions  of  syphilis — not  as 
a  routine  treatment,  but  as  one  of  reserve  and  exigency. 

Mercurial  baths  are  useful  during  the  whole  secondary  stage  of  svph- 
ilis,  and  also  in  the  tertiary  period.  They  may  be  employed  to  remove 
some  obstinate  local  lesion  or  to  expedite  the  disappearance  of  a  general 
rash.  Late  secondary  rashes  rebellious  to  other  methods  are  frequently 
dispelled  by  this  with  promptitude.  Neuralgias,  rheumatoid  pains, 
cephalalgias,  pains  in  joints  and  fasciae  are  often  promptly  relieved  by 
mercurial  baths.  In  cases  in  which  for  any  reason  other  methods  of 
treatment  are  contraindicated  we  may  resort  to  mercurial  fumigations 
with  marked  benefit. 

Many  preparations  of  mercury  have  been  used  in  this  form  of  treat- 
ment, but  calomel  and  cinnabar  are  the  agents  upon  which  experience 
has  shown  that  most  reliance  may  be  placed.  To  obtain  good  and  satis- 
factory results  these  drugs  must  be  pure  and  free  from  admixture. 

When  calomel  is  used,  from  40  to  60  grains  may  be  placed  upon 
the  lamp,  but  in  some  cases  even  90  grains  may  be  required.  The 
large  doses  of  calomel  administered  with  moist  vapor  are  generally  used 
in  cases  of  severity  and  of  exigency,  and  are  not  to  be  frequently  re- 
peated. Cinnabar  may  be  used  in  somewhat  larger  quantity  than 
calomel,  but  in  general  my  practice  is  to  combine  the  two  salts  in  one 
bath.     As  an  average  dose  I  have  found  that  20  grains  of  calomel  and 


688     THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS. 

40  of  cinnabar  fused  simultaneously  in  connection  with  moist  heat  pro- 
duce prompt  and  safe  results.  This  dose  may  be  increased  or  diminished 
according  to  the  condition  of  the  case.  In  large  cities  there  are  usually 
one  or  more  establishments  in  which  these  baths  are  given  under  the 
advice  of  physicians.  In  that  case  the  physician  need  only  prescribe 
the  dose  and  the  number  of  baths  which  he  desires  the  patient  to  take, 
and  the  bath  attendants  wTill  carry  out  his  wishes. 

When  the  baths  are  unobtainable  or  when  the  patients  object  to 
visit  the  bath  establishment,  this  method  may  be  pursued  at  home. 
For  this  purpose  it  is  necessary  to  use  either  Lee's  or  Maury's  lamp, 
by  means  of  which  the  mercurial  salt  is  volatilized  and  steam  generated 
at  the  same  time.  The  patient  is  stripped  and  enveloped  in  one  or 
more  blankets  or  in  coverings  made  for  the  purpose  of  mackintosh  or 
India-rubber  lined  with  flannel,  and  the  flame  started.  In  a  few 
minutes  perspiration  is  induced,  and  the  evaporated  calomel  is  deposited 
upon  the  body.  Usually  the  protective  garments  fit  closely  at  the  neck, 
but  in  some  there  is  a  slight  opening,  through  which  some  of  the  fumes 
may  escape  and  may  be  absorbed  in  respiration.  When  deemed  neces- 
sary by  the  physician,  the  patient  may  inhale  some  of  the  fumes,  but  it  is 
always  well  to  allow  some  air.  Twenty  to  thirty  minutes  are  sufficient 
for  a  bath,  after  which  the  patient  is  allowed  to  cool  off  slowly.  When 
practicable  the  patient  should  retire  at  once  to  bed,  preferably  enveloped 
in  the  garment  worn  during  the  bath.  It  is  well,  if  the  patient  has  to 
dress  and  go  home,  that  as  little  friction  of  the  skin  as  possible  should 
be  practised,  in  order  not  to  rub  off  the  minute  particles  of  mercury. 
In  cold  weather  care  should  be  taken  that  the  patient  is  properly  pro- 
tected when  he  goes  out  after  the  bath. 

These  baths  should  never  be  taken  directly  after  meals.  It  is  better 
that  they  should,  if  possible,  be  taken  just  before  going  to  bed  or  in 
the  evening  ;  but  in  any  case  fully  two  hours  should  elapse  after  a  meal. 
As  a  rule,  patients  should  be  in  good  condition  as  to  their  stomachs  and 
bowels  when  they  are  subjected  to  this  treatment,  and  they  must  be 
rigidly  prohibited  from  using  alcoholics.  While  undergoing  mercurial 
vapor  treatment  the  patient  should  be  carefully  watched  in  order  that  no 
drawbacks  may  be  encountered.  Thus  if  he  complains  of  feeling  tired 
and  debilitated  after  a  bath,  it  will  be  necessary  to  reduce  the  quantity 
of  mercury  and  also  the  amount  of  water  to  be  evaporated.  In  many 
cases  harm  is  done  by  using  too  much  steam  vapor.  Some  patients  com- 
plain of  headache,  and  it  is  then  necessary  to  administer  a  purge  or  to 
decrease  the  amount  of  food  ingested. 

It  is  well  to  begin  by  giving  one  bath  every  other  day,  and  then  to 
increase  to  a  bath  daily  if  the  necessity  of  the  case  demands  it.  Some 
patients  bear  these  daily  baths  well,  while  others  experience  unpleasant 


HYPODERMIC  INJECTIONS  OF  MERCURY.  689 

symptoms  from  them.  As  a  rule,  after  one  or  two  baths  improvement 
is  observed,  but  in  some  cases  a  beneficial  effect  is  delayed  for  a  week  or 
two.  The  number  of  baths  to  be  taken  can  only  be  determined  by  the 
condition  of  the  case.  In  general  it  may  be  said  that  a  course  of  baths 
extending  over  one  or  two  months  will  be  sufficient.  This  period,  how- 
ever, may  be  lengthened.  In  many  cases  only  a  few  baths  are  neces- 
sary, they  being  employed  for  some  temporary  condition  or  as  an  adju- 
vant to  other  methods  of  treatment. 

While  a  patient  is  thus  being  treated  the  physician  should  carefully 
watch  the  state  of  his  gums  and  of  the  gastro-intestinal  tract,  and 
remedy  any  disturbance.  It  is  not  uncommon  to  observe  a  mild  form  of 
mouth  lesions  in  patients  taking  a  course  of  mercurial  baths.  This 
condition  may  be  cured  by  local  means  and  by  the  temporary  suspen- 
sion of  the  baths  or  by  diminishing  the  quantity  of  the  mercurial  em- 
ployed. Sometimes,  when  large  doses  have  been  frequently  used,  a 
sudden  and  violent  colitis  is  developed.  This  condition,  painful  and 
sometimes  alarming,  is  readily  cured  by  rest,  cessation  of  treatment,  and 
the  use  of  opiates. 

HYPODERMIC  INJECTIONS  OF  MERCURY. 

Although  all  the  preparations  of  mercury,  both  soluble  and  insoluble, 
have  been  used  hypodermically  in  the  treatment  of  syphilis,  but  one  of 
them,  the  bichloride,  has  stood  the  test  of  time.  Whereas  in  earlier 
days  the  claim  was  made  that  this  treatment  was  applicable  to  all  forms 
and  stages  of  syphilis,  the  conviction  has  gained  ground  that  it  is  a 
method  (valuable  in  very  many  instances)  of  reserve,  emergency,  utility, 
or  expediency.  Thus  in  cases  in  which  mercury  is  badly  borne  by  the 
stomach,  and  acts  as  a  depressant  and  impairs  nutrition,  it  is  common  to 
observe  that  these  injections  are  well  borne,  and  that  an  era  of  improve- 
ment is  inaugurated.  Again,  in  cases  of  intestinal  disorder,  in  which 
pain  and  diarrhoea  always  follow  the  stomach-dose,  subcutaneous  injec- 
tions are  beneficial.  In  many  cases  when  by  stomach  ingestion  a  mild 
or  severe  stomatitis  or  salivation  is  produced,  or  when  local  medication 
is  without  effect,  the  substitution  of  hypodermic  injections  will  often  be 
followed  by  toleration  of  the  drug.  The  injections  are  often  of  much 
value  in  local  and  regional  therapy,  as,  for  instance,  in  cases  of  localized 
syphilitic  neoplasms,  resisting  internal  treatment,  in  eye,  ear,  and  cere- 
bral affections,  and  in  hyperplasia  of  the  lymphatics  and  the  ganglia. 
In  the  past  few  years  I  have  observed  much  benefit  from  the  hypoder- 
mic injection  of  corrosive  sublimate  in  patients  who  were  suffering  from 
la  grippe,  and  in  whom  the  secondary  manifestations  of  syphilis  were 
coincidently  present.  In  many  of  these  cases  mercury  by  the  stomach 
was  badly  borne  and  produced  debility  and  great  nervousness  ;  in  others 

44 


690     THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS. 

the  stomach  was  fully  taxed  by  the  antigrip  remedies  ;  and  in  still  others 
it  seemed  to  have  no  effect.  In  these  conditions  I  resorted  to  the  subli- 
mate injections,  with  a  promptly  beneficial  effect  and  ultimate  good  results 
upon  the  syphilitic  diathesis.  It  is  well  to  bear  these  facts  in  mind,  for 
they  will  be  the  means  of  helping  many  a  sorely  tried  patient. 

In  many  cases  of  secondary  syphilis  it  will  happen  that  by  reason 
of  colds,  of  intercurrent  acute  affections  of  the  throat,  lungs,  liver,  and 
intestines,  and  of  gastric  derangements,  mercury  by  the  mouth  is  tempo- 
rarily contraindicated  ;  and  in  these  exigencies  resort  may  be  had  to 
hypodermic  medication.  Patients  sometimes  become  tired  and  complain 
of  the  dosing  by  pills,  and  circumstances  do  not  favor  the  use  of  in- 
unctions or  fumigations ;  in  these  cases  very  often  quiet  and  content- 
ment may  be  produced  by  using  mercury  subcutaneously.  In  some 
cases — happily  rare — the  evolution  of  the  secondary  stage  of  syphilis 
is  ushered  in  with  fever  and  marked  debility  and  malaise ;  in  fact,  a 
pseudotyphoid  state  is  produced.  In  such  cases  there  is  very  often 
stomach  intolerance  of  mercury,  and  the  patient  is  too  weak  to  stand 
mercurial  inunctions.  In  this  emergency  we  can  use  hypodermic  injec- 
tions of  sublimate  with  confidence,  and  employ  the  stomach  for  symp- 
tomatic remedies. 

Within  the  limits  of  expediency,  emergency,  and  utility  these  injec- 
tions possess  the  advantages  of  smallness  and  precision  of  dose  and  ease 
of  administration,  a  promptly  satisfactory  therapeutic  action,  and  the 
absence  of  systemic  disturbance. 

Extended  experience  has  convinced  me  that  the  most  efficient  dose 
of  the  bichloride  when  used  hypodermically  is  \  of  a  grain,  and  it  may 
in  some  cases  be  increased  to  even  -|  or  ^  of  a  grain.  It  is  usually 
well  to  begin  with  the  injection  of  ^  of  a  grain,  and  to  increase  carefully 
up  to  £  of  a  grain,  and,  if  necessary,  even  higher.  In  average  well- 
developed  men  these  doses  are  well  borne,  and  will  exert  a  favorable 
influence  upon  the  disease  and  produce  no  bad  results.  In  former  years 
these  doses  would  have  been  considered  toxic,  but  I  have  given  so  many 
thousands  of  them  with  much  benefit  to  patients,  that  I  have  reached 
the  conclusion  that  it  is  only  within  the  past  few  years  that  we  have 
realized  the  full  curative  effect  by  this  method. 

The  bichloride  solution  should  be  freshly  made  and  so  adjusted 
that  10  drops  of  distilled  water  will  contain  }  of  a  grain  of  the  salt. 
This  solution  should  be  kept  in  a  dark  place. 

Method  of  Injection. — The  syringe  should  be  made  of  India-rubber, 
and  should  hold  10  or  20  drops.  The  needles  should  be  of  very  fine 
calibre,  of  steel,  and  fully  an  inch  and  one-eighth  or  one-quarter  long. 
The  greatest  care  should  be  taken  to  keep  the  syringe  and  needles  (for 
it  is  well  to  have  quite  a  number)  in  a  state  of  perfect  cleanliness  and 


HYPODERMIC  INJECTIONS   OF  MERCURY.  691 

removed  from  dust  contamination.  When  the  syringe  is  charged  with  the 
sublimate  solution  and  the  needle  is  affixed,  the  instrument  should  be 
placed  in  a  saucer  or  tray  containing  a  5  per  cent,  carbolic  acid  solution. 
In  the  operation  complete  asepsis  should  be  aimed  at :  the  injected  part 
should  be  carefully  washed  with  soap  and  water,  mopped  with  carbolic 
acid  solution  (5  per  cent.),  and  dried.  The  skin  being  pinched  up  in  a 
fold,  the  needle  is  to  be  pushed  gently  but  firmly  deep  into  the  sub- 
cutaneous connective  tissues,  and  the  fluid  expelled  slowly  and  with 
care,  in  order  that  the  tissues  may  not  be  bruised  more  than  necessary. 
Slight  massage  over  the  site  of  injection  will  aid  in  its  diffusion  into 
the  tissues.  It  must  always  be  borne  in  mind  that  the  fluid  should  not 
be  thrown  into  the  deep  parts  of  the  derma  proper,  for  the  reason  that 
if  there  deposited  it  is  very  prone  to  produce  an  eschar,  which  will  result 
in  destruction  of  the  whole  thickness  of  the  skin.  Then,  again,  great 
care  must  be  exercised  that  the  point  of  the  needle  is  not  in  a  vein,  in 
which  case  dizziness,  syncope,  a  feeling  of  suffocation,  pain  in  the  heart 
and  lungs,  and  other  alarming  symptoms  will  be  observed.  To  avoid 
this  accident  the  surgeon  must  watch  the  piston  of  the  syringe  while 
he  is  injecting.  If  there  is  a  moderate  resistance  to  the  injected  fluid, 
as  will  be  the  case  if  the  tip  is  in  the  subcutaneous  tissues,  he  may  know 
that  all  is  well.  If,  however,  the  injection  seems  to  pass  out  of  the 
syringe  without  any  or  with  very  little  resistance,  there  is  danger  that 
the  tip  is  in  a  vein.  Under  these  circumstances  it  is  well  to  push  down 
farther  or  withdraw  the  needle  a  little  until  normal  resistance  is  felt, 
and  no  untoward  symptoms  threaten.  A  very  moderate  amount  of 
practice  in  the  use  of  hypodermic  injections  will  teach  the  surgeon  to 
know  when  he  is  in  danger  of  doing  harm. 

The  depressions  just  behind  the  great  trochanters  are  eligible  sites 
for  injections.  Injections  made  here,  as  a  rule,  cause  little  if  any  pain, 
and  but  small  and  ephemeral  nodosities,  In  this  region  quite  a  number 
of  injections  may  be  given,  and  in  most  instances  sufficient  surface  is 
offered  for  the  requisite  injection-treatment.  We  can  resort  also  to  the 
hypogastric  regions  and  to  the  parts  near  the  inguinal  lymphatics,  above 
and  below ;  but  whenever  the  upper  parts  of  the  thighs  are  used  great 
care  must  be  exercised,  in  order  that  we  can  continue  the  treatment. 
As  it  is  very  often  important  to  act  locally  upon  lesions  of  the  penis 
and  of  the  lymphatics  arising  therefrom,  we  may  have  to  utilize  the 
tissues  in  their  vicinity.  It  should  always  be  remembered  that  injections 
should  not  be  made  into  the  mons  veneris  or  under  the  skin  of  the 
penis.  The  region  of  the  neck,  particularly  its  back  portions,  may  be 
used  in  extreme  cases  requiring  local  or  regional  therapy.  Care  must 
be  exercised  that  vessels  and  nerves  are  not  punctured  or  injured. 
Whenever  mercurial  injections  are  employed  for  localized  deposits  of 


692     THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS. 

new  growths  the  anatomical  peculiarities  of  the  parts  must  be  taken  into 
consideration. 

As  a  rule,  the  injection  of  -|-  or  \  of  a  grain  of  sublimate  every 
second  day  will  not  be  attended  with  annoying  results,  and  even  a  daily 
injection  may  be  well  borne  and  may  produce  good  results.  No 
absolute  rule  can  be  given  as  to  the  dose  or  its  frequency.  As  has 
been  said,  each  case  is  a  problem,  and  when  treated  with  injec- 
tions, as  with  all  methods  of  antisyphilitic  therapy,  it  must  be  carefully 
watched.  If  the  general  condition  of  the  patient  is  improved,  if  his 
lesions  show  signs  of  yielding  to  treatment,  and  if  the  annoyances 
and  discomforts  of  his  disease  are  ameliorated,  the  physician  may 
be  assured  that  he  is  on  the  right  track,  and  he  can  increase  the 
dose  or  the  frequency  of  the  injections  according  to  the  indications 
presented.  It  is  astonishing  how  seldom  stomatitis  or  intestinal 
troubles  are  produced  even  when  massive  doses  of  the  sublimate  are 
injected. 

The  unpleasant  local  effects  are  as  follows :  pain  at  the  point  of 
puncture  ;  pain  at  the  site  of  the  injection ;  an  erythematous  condition 
of  the  skin,  with  heat  and  itching  or  burning;  infiltration  of  the 
subcutaneous  tissues,  and  localized  firm  nodosities. 

The  pain  at  the  point  of  puncture  is  usually  trifling,  and  abscess  is 
seldom  caused  in  this  era  of  asepsis. 

The  pain  at  the  site  of  injection  may  be  severe,  but  as  a  rule  it  ceases 
in  a  few  hours.  It  may  last  one  or  more  days,  and  leave  a  sensation 
of  tenderness  and  soreness  of  varying  degrees.  In  many  cases  it  will 
be  observed  that  pain  is  felt  after  the  first  few  injections,  and  that 
thereafter  it  is  not  complained  of.  The  temperament  of  the  patient  in 
this  ordeal,  as  in  disease  in  general,  has  much  to  do  with  the  presence 
or  absence  of  pain  following  injections. 

An  erythematous  halo  may  often  be  observed  even  when  the  utmost 
care  has  been  taken  with  the  injection.  As  a  rule,  this  hyperemia  is 
slight  and  ephemeral,  and  causes  little  annoyance.  In  some  cases  the 
redness  is  deep,  and  the  burning  and  itching  are  severe.  It  is  a  con- 
dition readily  relieved  by  rest  and  cooling  lotions. 

Infiltration  into  the  subcutaneous  tissues  may  be  of  various  grades 
of  severity.  In  exceptional  cases  it  presents  many  of  the  objective 
features  of  erythema  nodosum.  We  may  also  find  extensive  induration 
of  a  brawny  character,  which  may  or  may  not  be  painful.  In  some 
instances  prompt  involution  occurs,  but  in  others  the  thickened  condition 
is  persistent.  In  some  cases  each  injection  gives  rise  to  a  localized  mar- 
ginated  subcutaneous  tumor  which  presents  a  feeling  of  firm  structure. 
These  nodosities  remain  in  an  indolent  condition  for  a  time,  and  then 
disappear. 


DRAWBACKS  EXPERIENCED  IN  TREATMENT  OF  SYPHILIS.   693 

Abscesses,  such  as  follow  calomel  injections,  are  not  observed  follow- 
ing sublimate  injections. 

Injection  of  mercurial  salts  into  veins  (a  procedure  recently  ex- 
ploited) is  a  very  dangerous  method,  and  should  not  be  used.  If  the 
surgeon  likes  to  wander  into  the  field  of  experimentation,  he  may  use 
other  soluble  mercurial  salts — i  e.,  the  salicylate ;  but  he  will  find  in 
the  end  that  none  of  them  is  better  than  the  bichloride. 

Calomel  and  other  insoluble  salts  of  mercury  have  been  used  hypo- 
derm  ically  in  the  treatment  of  syphilis,  but  their  use  is  attended  by 
many  dangers,  local  and  constitutional.  Calomel  injections  will  some- 
times produce  excellent  results,  but  such  can  also  be  obtained  from  the 
use  of  bichloride  injections  and  by  inunctions. 

Calomel  and  other  insoluble  preparations  of  mercury  when  injected 
under  the  skin  may  produce  intractable  salivation,  severe  enteritis  and 
colitis,  intestinal  ulceration,  infarction  of  the  lungs  and  parenchymatous 
nephritis,  and  anuria. 

THERMAL   SPRINGS  AND  BATHS. 

The  various  hot  springs  of  this  and  other  countries  do  not  possess 
any  specific  action  whatever  upon  syphilis  or  upon  syphilitic  lesions. 
When  patients  go  to  these  places  they  are,  so  to  speak,  on  their  good 
behavior,  and  they  follow  treatment  regularly  and  lead  a  temperate  and 
wholesome  life.  The  warm  and  hot  baths  are  beneficial  in  promoting 
metabolism,  and  the  air  and  exercise  alternating  with  rest  and  quiet 
have  a  decidedly  beneficial  effect.  But  all  these  conditions  and  benefits 
can  be  obtained  in  most  country  places  and  pleasure-resorts.  In  any 
country  place  and  at  the  seaside  patients  can  take  more  antisyphilitic 
medication  than  when  at  home,  and  this  is  the  main  feature  insisted 
upon  by  those  who  advocate  the  various  hot  springs.  In  most  cases  the 
syphilitic  who  makes  this  long  and  tiresome  pilgrimage  has  not  been 
well  treated  at  home;  hence  has  not  done  well.  So  he  seeks  the  relief 
which  he  thinks  he  can  derive  in  some  mysterious  manner  from  thermal 
baths. 

Take  away  mercurial  ointment  and  iodide  of  potassium  from  any 
thermal  spring,  and  its  business  will  soon  close  up  for  want  of  patronage. 

DRAWBACKS  SOMETIMES  EXPERIENCED  DURING  THE 
TREATMENT  OF  SYPHILIS. 

Mouth   and  Nasopharynx. 

During  the  administration  of  mercury,  particularly  when  long  con- 
tinued and  in  large  doses,  salivation  is  liable  to  occur.  This  accident 
may  be  prevented  by  guardedly  prescribing  the  dose  and  by  continually 


694     THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS. 

watching  the  patient.  With  the  onset  of  salivation  mercurial  treatment 
should  be  abruptly  stopped,  and  local  antiseptic  and  astringent  remedies 
employed  at  once. 

The  most  common  symptom  of  mild  salivation  produced  by  mer- 
cury is  a  sensation  of  soreness  in  the  gums,  felt  chiefly  when  cleaning 
the  teeth,  and  also  in  mastication,  or  from  contact  with  vinegar  or  other 
acid  fluids.  Many  patients  first  experience  uneasiness  and  pain  around 
one  or  both  wisdom  teeth.  In  either  of  these  instances  of  gingivitis 
we  find  the  gums  red,  swollen,  and  exulcerated,  and  perhaps  at  their 
teeth-margin  covered  with  a  film  of  necrotic  tissue  or  membrane  which 
consists  of  microbes  and  degenerated  epithelial  cells.  In  some  cases 
this  condition  is  confined  to  the  interdental  prominences  of  the  mucous 
membrane ;  in  others  the  entire  gums  are  swollen,  softened,  and  tender. 
Under  these  circumstances  the  teeth  often  feel  tender,  and  even  painful ; 
they  become  loose,  and  the  patient  feels  that  they  are  longer  than  usual. 
In  very  severe  cases  they  drop  out.  As  concomitants  of  this  state  there 
is  a  metallic  taste  in  the  mouth  and  the  breath  is  more  or  less  fetid. 
Other  patients  first  complain  of  a  metallic  taste  in  the  mouth,  and  it 
will  be  noticed  then  that  the  breath  is  offensive,  or  before  the  super- 
vention of  these  symptoms  they  may  observe  that  the  quantity  of  saliva 
is  increased,  and  is  more  or  less  viscid.  Inspection  of  the  mouth  then 
shows  a  general  condition  of  oedematous  hyperemia.  The  gums  and 
the  mucous  membrane  of  the  cheeks,  at  the  root  of  the  tongue,  and  of 
the  pharynx  are  of  a  deep-red  or  a  whitish-red  color.  The  submaxillary 
glands  may  be  swollen  and  painful,  and  the  parotid  may  likewise  be 
affected.  Unless  the  process  ceases,  either  spontaneously  or  as  a  result 
of  treatment,  the  swelling  of  the  parts  increases  ;  the  tongue  swells ;  the 
mouth  can  with  difficulty  be  opened,  and  then  not  to  its  full  extent ; 
the  teeth  make  deep  indentations  in  the  mucous  membrane  of  the 
cheeks,  and  ulcerations  may  occur.  In  these  severe  cases  the  suffering 
of  the  patient  is  very  distressing,  and  deglutition  is  more  or  less  im- 
paired. The  patient  cannot  chew  or  partake  of  solid  food,  and  has  to 
rely  upon  milk  and  nutritious  liquids  for  sustenance.  To  add  to  his 
trouble,  he  becomes  weak,  nervous,  restless,  and  apprehensive;  he  sleeps 
little,'  and  has  no  comfort  anywhere.  His  pallid,  anxious  facies,  his 
immobile  and  perhaps  swollen  mouth  and  lips,  together  with  the  con- 
stant flow  of  viscid  saliva  and  the  fetid  breath,  present  a  truly  pitiable 
spectacle.  Luckily,  we  now-a-days  seldom  see  these  formidable  cases 
of  salivation. 

The  mouth-lesions  produced  by  the  use  of  mercury  are  certainly 
less  common  now  than  years  ago.  As  a  rule,  most  patients  bear  mercury 
well ;  others  are  at  first  moderately  affected  by  it ;  while  in  a  few  cases 
its  use  in  a  short  time  produces  toxic  effects  of  greater  or  less  severity. 


INTESTINAL   QANAL.  695 

There  is  no  point  deserving  of  greater  emphasis  in  the  treatment  of 
syphilis  than  that  it  is  most  essential  to  keep  the  mouth  and  nasopharynx 
in  a  healthy  condition.  These  cavities  should  be  examined  from  time 
to  time,  and  any  inflammatory  or  otherwise  abnormal  condition  should 
be  treated  at  once. 

Treatment  of  Gingivitis,  Stomatitis,  and  Salivation. — A  patient 
under  mercurial  treatment  should  be,  as  before  stated,  carefully  watched 
as  to  the  condition  of  his  mouth,  throat,  and  nose.  When  there  is  any 
tendency  to  hyperemia  of  the  mouth  and  throat,  free  rinsing  three  or 
four  times  a  day  with  solutions  of  chlorate  of  potassium  and  alum,  of 
common  salt,  or  of  borax  should  be  employed.  "When  patients  are  under- 
going an  inunction  cure,  particularly,  it  is  well  to  wash  the  mouth  three 
or  four  times  a  day  with  strong  alum-water  or  with  a  solution  of  alum 
and  acetate  of  lead. 

The  first  signs  of  irritation  of  the  gums  indicate  the  necessity  for  a 
diminution  of  the  dose  or  a  suspension  of  treatment  and  the  adoption 
of  local  therapeutics.  In  all  cases  of  mercurial  action  upon  the  mouth 
the  physician  should  be  very  conservative  in  the  use  of  caustic  applica- 
tions. For  mild  cases  of  gingivitis  the  application  with  a  brush  of  equal 
parts  of  tincture  of  myrrh  and  tincture  of  iodine  once  a  day,  followed 
by  some  mild  mouth-wash,  will  usually  be  all-sufficient.  When  the 
case  is  severe,  and  the  tissues  of  the  mouth  and  throat  are  much 
inflamed  and  swollen,  frequent  rinsing  with  very  warm  solutions  of 
borax  and  alum,  to  which  listerine  aud  glycerin  are  added,  are  very 
soothing.  Once  or  twice  a  day  it  may  be  necessary  to  use  as  a  mouth- 
wash and  gargle  a  solution  of  the  nitrate  of  silver  (4  to  8  grains  to  the 
ounce).  Much  benefit  often  follows  rinsing  the  mouth  with  a  solution 
of  bichloride  of  mercury.  For  -this  purpose  Von  Swieten's  solution, 
either  of  full  strength  or  diluted,  will  prove  very  efficacious.  Patients 
thus  suffering  should  be  well  nourished  by  means  of  nutritious  broths 
and  sarco-peptones,  and  should  take  quinine  freely.  They  should  be 
kept  in  the  fresh  air  as  much  as  possible.  Much  benefit  and  comfort 
may  be  derived  from  the  application  of  a  solution  of  cocaine  to  ulcer- 
ated surfaces.  The  judicious  use  of  hot  baths  will  aid  in  the  elimina- 
tion of  the  mercury  from  the  system. 

Intestinal  Canal. 

Many  patients  who  have  taken  mercury,  even  in  comparatively 
small  quantities,  for  a  long  or  even  short  period,  begin  to  complain  of 
symptoms  referable  to  the  stomach.  They  say  that  they  have  flatulence 
and  sour  stomach,  and  that  their  digestion  is  weak.  In  its  early  days 
this  condition  may  not  be  accompanied  by  bodily  weakness,  but  its  con- 
tinuance is  complicated  by  general  debility,  pallor  of  countenance,  indis- 


696     THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS. 

position  to  exertion,  and  even  a  depression  of  the  nervous  system  of 
such  marked  intensity  that  we  may  call  it  neurasthenia.  This  condition 
is  also  produced  by  combinations  of  mercury  and  iodide  of  potassium. 

The  most  common  form  of  disturbance  of  the  intestinal  canal  due  to 
the  ingestion  of  mercury  is  a  mild  form  of  enteritis,  which  is  attended 
with  colicky  pains,  borborygmus,  and  diarrhoea.  In  many  cases  this 
condition  is  very  ephemeral  and  passes  away  in  a  few  days,  during 
which  the  system  is  becoming  accustomed  to  the  action  of  the  drug. 
The  pain  and  disturbance  are  felt  shortly  after  taking  the  dose,  and  last 
for  an  hour  or  more,  and  then  pass  off,  to  follow  in  like  manner  the  next 
dose.  In  other  cases  the  effect  is  more  severe  and  lasting,  and  the 
patient  becomes  weak.  To  prevent  this  untoward  action  of  mercury, 
the  utmost  care  must  be  exercised  in  the  matter  of  diet,  which  should 
be  bland  and  easily  digestible,  and  in  the  avoidance  of  large  quantities 
of  fluids  and  of  alcoholic  and  malt  liquors. 

In  some  cases  in  which  pills  are  taken,  but  chiefly  in  those  in  which 
inunctions,  fumigations,  and  hypodermic  injections  are  actively  given, 
colitis  of  different  degrees  is  produced.  This  condition  is  attended 
with  much  pain  and  discomfort,  and  with  a  diarrhoea  which  may  be  so 
severe  as  to  be  bloody.  Under  these  circumstances  the  specific  treat- 
ment must  be  temporarily  suspended  and  the  bowel  affection  treated 
symptomatically. 

Mercurial  Cachexia. 

A  general  depression  and  impairment  of  the  nutrition  of  the  body 
sometimes  occur  quite  early  after  the  ingestion  or  absorption  of 
mercury.  But  those  cases  in  which  it  may  be  said  that  there  is  an 
intolerance  to  mercury  are  happily  rare.  In  most  of  them  it  will  be 
found  that  if  the  mercurial  by  the  mouth  be  stopped,  and  its  guarded 
use  by  inunction  or  hypodermic  injection  be  substituted,  the  intolerance 
will  cease,  and  that  the  drug  will  work  satisfactorily. 

As  a  result  of  greatly  prolonged  mercurialization,  general  debility 
and  impaired  nutrition  of  the  body  are  frequently  produced.  In  many 
of  these  cases  the  syphilitic  diathesis  is  still  active,  new  lesions  appear, 
while  old  ones  persist,  and  coincidently  the  patient  begins  to  look 
pallid  and  sickly,  to  be  weak  and  apathetic,  and  to  suffer  more  or 
less  from  nervous  depression.  This  condition  is  a  frequent  outcome 
of  the  continuous  mercurial  treatment,  and  is  sometimes  seen  in  per- 
sons who,  fearful  of  the  disease,  have  an  insensate  and  irresistible 
desire  continually  to  dose  themselves  with  mercury.  It  is  attended 
with  dilatation  of  the  stomach,  gastro-enteritis  of  a  mild  and  chronic 
type,  perhaps  colitis,  and  a  general  impairment  of  the  nervous  system 
and   of  the  nutritional   powers   of  the  body.     Under  an   enlightened 


TOXIC  EFFECTS  OF  THE  IODIDES.  697 

system  of  antisyphilitic  therapeutics  in  its  broadest  sense  such  conditions 
as  these  can  be  readily  avoided. 

Toxic  Effects  of  the  Iodides. 

Considering  the  large  number  of  people,  old  and  young,  who  for 
longer  or  shorter  periods  take  iodide  of  potassium,  it  must  be  admitted 
that,  in  general,  the  remedy  is  well  borne  by  the  human  system.  There 
are,  however,  many  with  whom  the  drug  disagrees  more  or  less 
actively.  These  persons  are  said  to  have  the  iodide-of-potassium  idio- 
syncrasy ;  that  is,  that  in  one  way  or  another  the  drug  produces  un- 
pleasant and  even  toxic  effects  in  them,  which  are  grouped  under  the 
general  term  iodism.  We  also  read  of  iodide-of-potassium  intolerance; 
but  the  truth  is  that  the  cases  are  exceptional  in  which  the  drug  is  so 
badly  borne  that  its  use  has  to  be  permanently  suspended.  While  there 
are  many  persons  who  have  a  greater  or  less  idiosyncrasy  against  the 
iodide,  there  are  few  who  are  wholly  intolerant  of  its  use. 

There  are  many  peculiar  facts  connected  with  the  iodide  idiosyncrasy. 
In  some  cases  a  small  dose  (a  fractional  part  of  a  grain)  will  produce 
severe  and  even  alarming  effects,  and  we  may  be  unable  even  by  means 
of  many  expedients  to  overcome  the  intolerance.  In  other  cases  a  very 
small  dose  will  produce  unpleasant  and  even  severe  effects,  whereas  a 
large  one  will  be  well  borne,  either  at  first  or  after  several  trials.  In 
some  cases  I  think  that  we  (to  use  an  apt  expression)  "  weaken  "  too 
quickly,  and  give  up  the  drug  after  a  little  rebuff;  whereas  with  proper 
moral  courage  (the  urgent  necessity  existing)  we  can  increase  the  dose 
and,  by  persisting,  establish  toleration. 

The  toxic  effects  of  iodide  of  potassium  and  of  the  other  iodides  may 
be  mild  or  severe. 

Slight  or  severe  nausea  and  griping  pains  in  the  bowels  may  follow 
the  ingestion  of  iodide  of  potassium.  These  can  hardly  be  called  toxic 
effects,  however,  for  they  are  usually  readily  prevented  by  the  addition 
of  a  little  tincture  of  ginger  or  capsicum  to  the  mixture,  or  of  a  small 
quantity  of  tannin. 

The  most  common  early  symptom  of  iodism  is  a  metallic  taste  in  the 
mouth  and  throat,  with  sometimes  fetor  of  the  breath.  Coryza,  mild 
and  severe,  is  also  frequently  complained  of,  and  is  often  regarded  by 
patients  as  cold  in  the  head.  There  may  be  mild  conjunctivitis  and 
lachrymation  combined  with  the  coryza,  which  may  be  accompanied  by 
much  sneezing  and  irritation  of  the  nose  and  eyes,  and  very  often  severe 
pain  in  the  frontal  sinuses.  In  some  cases  what  is  called  iodide  grip  is 
observed.  In  these  rare  instances  the  upper  air-passages,  the  eyes, 
and  lachrymal  ducts  are  much  swollen  and  red.  The  face  becomes 
swollen,  and  a  red  blush  resembling  erysipelas  may  be  present.     The 


698     THE  GENERAL  METHODICAL   TREATMENT  OF  SYPHILIS. 

pharynx  becomes  red  and  swollen,  and  the  oedema  may  extend  to  the 
epiglottis  and  glottis.  The  patient  suffers  much  from  burning  sensa- 
tions and  pain,  from  dyspnoea,  hoarseness,  and  dysphagia.  Together 
with  this  formidable  condition  there  are  fever,  weakness,  pain  in  the 
head,  extreme  restlessness,  and  in  rare  cases  oedema  of  the  glottis. 

In  some  cases  salivation  occurs,  which,  however,  is  not  usually  as 
severe  as  that  due  to  mercury.  In  most  cases  it  is  of  a  mild  and 
ephemeral  character. 

Neuralgic  pains  in  the  head  or  jaws  are  very  frequently  complained 
of,  and  some  patients  suffer  from  severe  toothache  while  taking  this 
drug.  In  other  cases  there  is  swelling  of  the  parotid,  submaxillary, 
and  sublingual  glands,  which  gives  rise  to  very  uncomfortable  symp- 
toms in  the  neck. 

It  is  not  uncommon  to  see  cedematous  hyperplasia  of  the  soft  palate, 
of  the  tissues  around  the  root  of  the  tongue,  of  the  tongue  itself,  and 
of  the  pharynx  in  cases  of  acute  or  chronic  iodism.  This  condition  is 
very  distressing  and  persistent,  and  demands  prompt  and  efficient  local 
treatment. 

The  toxic  effects  of  the  iodides,  chiefly  of  potassium,  upon  the  skin 
are  very  numerous  and  multiform  in  character.  They  may  all  be 
classed  under  the  general  head  of  dermatitis,  of  which  we  find  a  papu- 
lar and  papulopustular  form  (urticarial),  tubercular,  tuberous,  nodular, 
bullous,  and  ulcerative.  Besides  the  essential  inflammatory  dermal 
lesions,  the  iodides  may  produce  purpura,  probably  from  their  defibrin- 
izing  effects  upon  the  blood.  In  some  cases  iodide  of  potassium  pro- 
duces such  rapid  and  feeble  action  of  the  heart  that  its  use  must  be 
given  up.  It  is  very  important  that  these  iodine  rashes  shall  not  be 
diagnosticated  as  syphilides  with   acute  exacerbation. 

Though  last  to  be  mentioned,  particular  attention  should  be  called 
to  the  gastro-intestinal  effects  and  intolerance  of  the  iodides,  chiefly  of 
the  iodide  of  potassium.  In  most  cases  the  stomach  receives  the  drug 
kindly ;  in  others  it  produces  a  feeling  of  discomfort  and  impairs  diges- 
tion. This  condition  may  soon  pass  off,  either  spontaneously  or  as  the 
result  of  proper  medication  and  alimentation.  In  other  instances  it  is 
a  very  serious  drawback,  necessitating  the  suspension  or  even  the  aban- 
donment of  the  drug.  It  is  always  well  (the  necessity  existing)  to  use 
every  possible  means  to  overcome  this  troublesome  complication.  After 
the  long  use  of  full  doses  of  the  drug  patients  very  often  complain  of 
distressing  dyspeptic  symptoms  and  of  weakness,  and  show  evidence 
of  emaciation.  Their  heart-action  may  be  weak  and  their  nervous 
system  profoundly  affected.  Indeed,  a  condition  of  cachexia,  or  even 
of  neurasthenia,  may  thus  be  induced.  In  such  cases  we  must  stop 
the  use  of  the  drug  at  once,  put  the  patients  upon  a  careful  regimen, 


TOXIC  EFFECTS  OF  THE  IODIDES.  699 

see  that  their  hygiene  is  made  satisfactory,  build  them  up  with  tonics, 
and  bring  to  their  aid  all  fortifying  influences. 

It  is  said  that  long-continued  use  of  the  iodides  may  produce  struct- 
ural lesions  of  the  kidney. 

Iodide  of  rubidium  has  proved  an  inert  remedy  in  the  treatment  of 
syphilis. 

A  number  of  new  remedies,  mostly  patented  and  all  widely  adver- 
tised, have  been  vaunted  as  ideal  substitutes  for  the  classical  mercurials 
and  for  iodide  of  potassium  ;  but  none  of  them  has  shown  any  reliable 
therapeutic  eifects. 


CHAPTER   XLIX. 

HEREDITARY  SYPHILIS. 

The  words  "congenital "  and  "  infantile"  are  used  to  designate  this 
variety  of  syphilis ;  the  former  lacks  precision,  and  the  latter  may  be 
applied  with  equal  propriety  to  the  hereditary  and  the  acquired  forms. 
The  term  hereditary  syphilis,  therefore,  seems  preferable. 

In  earlier  years  when  the  treatment  of  syphilis  was  less  efficient 
than  it  is  now,  the  mortality  of  hereditarily  syphilitic  children  was 
very  great ;  but  of  late  years  the  deaths  of  these  children  have  been 
much  less  numerous  and  the  course  of  this  disease  much  less  severe  and 
prolonged.  With  the  increased  effectiveness  of  the  treatment  of  the 
syphilis  of  the  parents  it  is  seen  nowadays  that  in  many  cases  the  off- 
spring escapes  the  infection  or  the  disease  is  less  severe  than  formerly. 
It  follows  from  these  statements  that  the  old-time  frightful  statistics 
concerning  hereditary  syphilis  are  now  out  of  date  and  possess  no 
scientific  value. 

The  symptoms  of  hereditary  syphilis  show  themselves  in  most  cases 
between  the  third  and  twelfth  week  after  birth.  In  case  of  the  infec- 
tion of  both  parents  having  occurred  just  prior  to  conception,  unless 
energetic  treatment  is  adopted  the  foetus  may  be  profoundly  affected 
and  die.  In  the  event  of  only  one  parent  being  recently  diseased,  it 
may  be  possible  by  prompt  and  energetic  treatment  of  the  mother 
to  save  the  child  from  infection  or  at  least  to  modify  favorably  its 
intensity. 

There  are  few  exceptions  to  the  rule  that  the  severity  of  the  disease 
decreases  with  each  succeeding  child.  The  danger  of  the  death  of  an 
infected  child  diminishes  as  it  grows  older,  and  freedom  from  symp- 
toms until  after  the  sixth  month  justifies  a  favorable  prognosis.  Death 
results  most  frequently  in  cachectic  children  and  from  gastro-intes- 
tinal  affections,  which  are  to  a  great  extent  dependent  on  visceral 
lesions. 

Syphilis  is  transmitted  only  to  the  second  generation ;  and  although 
several  authors  have  claimed  transmission  to  the  third  generation,  the 
cases  reported  as  showing  the  condition  have  failed  utterly  in  carrying 
conviction  to  one's  mind. 

The  course  of  hereditary  syphilis  differs  in  many  respects  from  that 
of  the  acquired  disease.     The  latter  always  begins,  as  we  have  seen,  by 

700 


HEREDITARY  SYPHILIS.  701 

the  development  of  a  local  lesion,  which  is  followed  by  a  definite 
secondary  period  of  incubation,  at  the  expiration  of  which  constitutional 
manifestations  appear,  while  the  hereditary  disease  presents  no  initial 
lesion  and  cannot  be  divided  into  stages.  Moreover,  while  many  of  the 
lesions  of  each  are  similar,  being  undoubtedly  caused  by  the  syphilitic 
poison,  on  the  other  hand,  a  large  number  of  those  in  the  hereditary 
form  are  merely  the  result  of  perverted  nutrition,  and  may  occur  in  any 
adynamic  disease.  Among  such  lesions  may  be  classed  certain  affections 
of  the  eyes,  peculiar  osseous  malformations,  hydrocephalus,  impaired 
growth  of  the  hair,  as  well  as  deafness  and  deaf-mutism,  the  ultimate 
cause  of  which  is  unknown. 

The  lesions  of  hereditary  syphilis  are  more  hypersemic  and  active 
than  those  of  the  acquired  form,  and  tend  to  involve  larger  surfaces. 
As  a  rule,  the  early  lesions  are  more  generally  distributed  and  are  more 
symmetrical  than  those  which  are  developed  later. 

Vesicular  and  bullous  syphilid.es,  so  rare  in  acquired  syphilis,  are 
quite  common  in  the  hereditary  form,  while  rupia  is  almost  unknown  in 
the  latter.  Affections  of  the  nasal  mucous  membrane,  which  are  infre- 
quent and  appear  late  in  the  former,  are  among  the  earliest  and  most 
reliable  diagnostic  symptoms  of  the  hereditary  disease.  Visceral  affec- 
tions are  much  more  common  in  the  latter  than  in  the  former,  frequently 
being  multiple,  and  coexisting  with  lesions  similar  to  those  of  the 
secondary  stage  of  the  acquired  disease.  Gummatous  and  connective- 
tissue  infiltrations  are  often  developed  before  birth,  and  are  more  diffuse 
and  symmetrical  when  they  appear  before  the  end  of  the  first  year  of 
life  ;  when  seen  after  that  period  they  may  present  the  characteristics 
of  the  acquired  form.  A  peculiar  and  constant  lesion  of  the  ossifying 
ends  of  the  long  bones  has  been  observed  during  the  early  months  of 
hereditary  syphilis.  Certain  bone-lesions  may  be  developed  at  a  later 
period  which  resemble  those  of  the  acquired  disease.  Affections  of  the 
nervous  system,  although  more  common  than  has  been  supposed,  are 
comparatively  rare  in  hereditary  syphilis. 

Evidences  of  hereditary  taint  usually  disappear  before  puberty, 
although  syphilitic  lesions  undoubtedly  hereditary  have  been  observed 
at  later  periods,  and  in  some  instances  after  years  of  apparent  latency. 
The  extent  to  which  inherited  syphilis  furnishes  immunity  to  the  acquired 
form  is  still  undetermined,  but  it  is  very  probable  that  a  child  heredi- 
tarily syphilitic  at  birth  may  suffer  a  mild  attack  if  he  should  be  infected 
by  syphilis  acquired  at  puberty  or  later. 

In  hereditary  syphilis,  as  in  the  acquired  disease,  the  same  tendency 
exists  to  the  development  of  tuberculosis,  and  this  dangerous  symbiosis 
is  always  to  be  feared  in  infected  children,  old  and  young. 


702  HEREDITARY  SYPHILIS. 

OUTLINE  OF  THE  COURSE  OF  HEREDITARY  SYPHILIS. 

The  duration  of  hereditary  syphilis  depends  altogether  upon  two 
conditions — the  intensity  of  the  diathesis  and  the  treatment.  It  is  not 
uncommon  for  children  to  present  mild  and  superficial  symptoms  for  a 
few  months  or  a  year,  and  then  become  blooming  and  healthy,  never 
again  to  be  affected  with  syphilitic  lesions.  Again,  severe  and  extensive 
lesions  may  be  exhibited  during  the  early  months,  which  relapse  at 
irregular  intervals  in  an  equally  intense  but  more  limited  form  for  a 
few  years ;  or  syphilitic  lesions  may  be  developed  from  time  to  time 
until  the  tenth  or  twelfth  year,  perfect  health  being  established  after 
that  time.  In  very  chronic  cases  symptoms  may  recur  more  or  less  fre- 
quently until  puberty.  My  observations  lead  me  to  the  conclusion  that 
they  do  not  appear  after  that  date.  In  general,  the  severity  of  heredi- 
tary syphilis  is  expended  within  the  first  few  years,  and  subsequent 
lesions,  although  possibly  extensive  and  deep,  do  not  show  the  malig- 
nancy of  early  ones. 

The  course  of  hereditary  syphilis  is  equally  as  chronic  as  that  of  the 
acquired  disease,  and  is  more  irregular  and  uncertain,  especially  when 
the  treatment  has  not  been  adequate  and  efficient.  For  this  reason 
the  lesions  cannot  be  arranged  in  chronological  order,  and  a  precise 
division  of  the  disease  into  stages  is  likewise  impracticable.  Visceral  and 
superficial  lesions  frequently  coexist ;  the  interval  between  early  and 
late  lesions  may  be  but  a  few  months  or  even  many  years. 

As  in  the  acquired  form,  so  in  hereditary  syphilis,  the  extensive 
superficial  exanthems  are  peculiar  to  the  first  months  of  the  disease. 
With  these  may  coexist  lesions  of  the  mucous  membranes,  of  the  bones, 
or  of  the  viscera.  Relapsing  syphilides  are  usually  less  extensive  than 
the  first  eruption,  and  their  lesions  are  less  numerous.  They  may  be 
composed  of  either  papules,  pustules,  or  vesicles,  the  eruption  being 
polymorphous  or  made  up  of-  one  variety  of  lesion.  The  course  of 
these  relapsing  syphilides  may  be  even  more  chronic  than  that  of  the 
first  eruption,  and  the  interval  between  the  two  may  be  a  few  weeks  or 
several  months.  Sometimes  the  second  rash  appears  before  the  complete 
disappearance  of  the  first.  It  may  be  said  that  these  relapses  of  general 
eruptions  are,  as  a  rule,  peculiar  to  the  first  two  or  three  years  of  the 
disease.  Subsequent  eruptions  are  of  another  order,  more  profound, 
more  localized,  and  less  likely  to  relapse.  These  later  orders  of  dermal 
lesions  may  be  papulotubercular  or  perhaps  pustular,  but  in  general  they 
are  tubercular,  tuberculo-ulcerous,  and  gummatous. 

These  cases  of  late  development  are  rather  rare,  although  I  have 
seen  fully  six  dozen  in  which  such  lesions  have  appeared  at  the  third, 
sixth,  eighth,  twelfth,  fifteenth,  and  twentieth  years.     In  fully  one-half 


OUTLINE  OF  THE  COURSE  OF  HEREDITARY  SYPHILIS.      703 

they  occurred  between  the  fourth  and  twelfth  years,  in  three-eighths 
between  the  third  and  fifth,  and  in  the  remainder  between  the  twelfth 
and  twentieth  years.  It  is  very  rare  to  see  dermal  lesions  extensive  and 
superficial  after  the  second  or  third  year,  they  being  usually  profound 
and  limited,  and  in  this  respect  differing  from  those  of  the  acquired 
disease.  Under  the  heading  of  syphilis  hereditaria  tarda  many  inter- 
esting cases  of  dermal,  osseous,  visceral,  and  cerebrospinal  lesions  have 
been  reported.  In  many  cases,  however,  the  history  of'  syphilis  is  very 
vague.     (See  Fig.  161.) 

Fig.  161. 


Typical  facies  of  a  child  suffering  from  hereditary  syphilis,  showing  opacity  of  the  cornese,  fall  of 
nose,  with  stenoses  and  the  sequelae  of  ulcers  of  mouth. 

In  the  majority  of  cases  the  development  of  visceral  lesions  takes 
place  in  intra-uterine  life,  and  their  course  after  birth  is  retrogressive. 
The  principal  organs  attacked  are  the  liver,  the  lungs,  the  brain,  and 
the  kidneys.  Our  knowledge  of  the  frequency  and  extent  of  their 
development  after  birth  is  incomplete.  Besides  the  cutaneous  and  vis- 
ceral lesions  of  the  first  year  or  two,  other  syphilitic  affections  are  fre- 
quently observed.  In  many  cases  the  diaphyso-epiphyseal  lesions  of  the 
bones  appear  during  intra-uterine  life  and  run  their  course  in  the  early 
months  of  the  disease,  possibly  relapsing  at  a  later  period  ;  or  they  may 
appear  for  the  first  time  during  the  first  year  of  life.  From  the  fourth 
up  to  the  twentieth  year  the  shafts  of  the  bones  may  be  affected  by 
periostitis,  and  joint-affections  often  occur. 


704  HEREDITARY  SYPHILIS. 

The  lesions  of  the  mucous  membrane  are,  like  those  of  the  skin, 
superficial  and  often  extensive  in  the  first  years  of  life  ;  at  later  periods 
they  are  circumscribed,  profound,  and  destructive.  Occasionally  iritis, 
choroiditis,  or  retinitis  occurs,  generally  between  the  third  and  sixth 
years,  while  we  observe  that  keratitis  may  appear  at  any  time  up  to  the 
fifteenth  or  even  twentieth  year. 

In  the  somewhat  rare  cases  of  hereditary  syphilis  presenting  cerebral 
and  nervous  symptoms,  it  has  been  noted  that  such  symptoms  and  nutri- 
tional affections  of  the  cranium,  teeth,  etc.,  begin  in  the  early  years  of 
life  and  leave  more  or  less  marked  traces. 

The  severity  of  hereditary  syphilis  exhausts  itself  within  the  first 
three  years  of  life  ;  whatever  symptoms  are  manifested  after  that  time 
are  developed  in  the  most  chronic  and  irregular  manner.  Therefore,  if 
any  division  of  the  disease  into  stages  were  to  be  made,  the  first  four 
years  might  be  considered  the  first  stage,  or  the  period  of  the  disease 
proper,  the  second  stage  extending  from  that  time  indefinitely,  but  not 
beyond  the  twentieth  year. 

In  considering  these  persistently  recurring  attacks  of  the  various 
forms  of  lesions  one  must  always  remember  that  with  the  advances 
now  made  in  our  therapeutics  in  many  cases  the  syphilitic  diatheses  may 
be  extinguished. 


SOURCE  OF  THE  INFECTION. 

Infection  of  the  child  may  be  derived  from  the  father  alone  or  the 
mother,  or  from  both. 

Influence  of  the  Father. 

So  many  undoubted  instances  of  the  transmission  of  syphilis  from 
father  to  child  have  been  reported  that  further  evidence  is  scarcely 
needed.  The  risk  of  contagion  from  the  father  is  in  proportion  to  the 
activity  of  his  symptoms.  If  procreation  takes  place  while  he  is  in  the 
first  period  of  incubation,  the  child  will  escape,  and  may  do  so  even 
during  the  secondary  period,  but  infection  is  more  probable  as  the  latter 
stage  advances.  Probably  the  malign  influence  begins  with  the  evolu- 
tion of  constitutional  manifestations. 

There  is  abundant  evidence  that  if  the  disease  is  not  treated  the 
sperm-cells  will  retain  the  syphilitic  virus  through  the  first  year,  since 
temporary  and  spontaneous  latency  of  the  disease  is  observed  only  at  a 
later  period.  On  the  other  hand,  mercurial  treatment  may  so  modify  the 
disease  that  the  child  will  escape  even  within  the  first  year.  We  see 
frequent  examples  of  this  when  men  recently  syphilitic  and  compelled 
to  marry  are  put  under  an  active  mercurial  course,  and  within  a  year 


INFLUENCE   OF  THE  MOTHER.  705 

become  fathers  of  children  who  never  show  the  slightest  evidence  of 
syphilis. 

This  paternal  transmission  is  called  germinative  or  spermatic  infec- 
tion ;  and  if  syphilis  is  really  a  disease  due  to  a  bacterium,  we,  guided  by 
analogical  evidence,  can  readily  understand  the  nature  of  the  process. 
As  pointed  out  by  von  During,  Pasteur's  discovery  that  "  the  germs 
of  the  disease  of  silkworms,  called  pebrin,  pass  into  the  ovulum  and 
into  the  spermatic  cells  of  the  infected  worm,  which  retains  its  power 
of  fecundation  and  germination,  and  transmits  the  infection  to  its  off- 
spring, throws  a  flood  of  light  upon  the  pathology  of  the  transmission 
of  syphilis  by  heredity.  When  to  this  evidence  we  add  the  results  of 
the  experiments  of  Maffuci  and  Baumgarten,  who  succeeded  in  infecting 
eggs  with  tuberculosis  and  in  detecting  that  disease  in  the  resulting 
chicken,  it  almost  seems  that  the  question  is  settled." 

Influence  of  the  Mother. 

In  order  that  syphilis  may  be  conveyed  by  the  mother  her  disease 
must  be  constitutional.  It  is  very  probable  that  the  ovule  of  the  female 
is  infected  in  the  same  way  as  are  the  spermatozoa  of  the  male. 

When  impregnation  occurs  later  than  within  two  weeks  of  the  evolu- 
tion of  general  manifestations  the  foetus  is  almost  inevitably  affected, 
and  the  activity  of  the  disease  in  the  child  will  be  in  proportion  to  that 
of  its  early  stage  in  the  mother,  unless  the  disease  has  already  been 
modified  by  active  mercurial  treatment. 

Statistics  show  that  such  embryos  rarely  reach  maturity,  abortion 
occurring:  usually  in  from  the  fifth  to  the  seventh  month,  sometimes  as 
early  as  the  third. 

In  such  cases,  in  addition  to  the  disease  of  the  ovule  itself,  the  nutri- 
tion and  growth  of  the  foetus,  which  depend  upon  the  richness  and  purity 
of  the  mother's  blood,  are  impaired  in  proportion  to  the  severity  of  the 
disease  in  the  mother. 

The  frequent  observation  that  the  product  of  conception  occurring 
while  either  parent  is  in  the  early  and  active  stage  of  the  disease  is 
intensely  syphilitic  or  fails  to  reach  maturity,  and  that  healthier  children 
are  produced  as  the  disease  in  the  parent  becomes  less  severe,  is  ground 
for  the  assertion  that  the  severity  of  the  syphilis  in  offspring  is  in  pro- 
portion to  its  activity  in  either  parent  at  the  time  of  conception.  Thus, 
if  a  syphilitic  woman  becomes  pregnant,  or  if  the  disease  is  derived 
from  a  man  in  whom  it  is  active,  the  first  foetus  may  live  only  to  the 
third  month.  Without  treatment  the  next  pregnancy  may  have  a 
similar  result,  gestation  possibly  continuing  a  little  longer.  As  the  dis- 
ease becomes  modified  by  time  or  treatment  a  living  but  syphilitic  child 
45 


706  HEREDITARY  SYPHILTS. 

may  be  born  ;  in  succeeding  pregnancies  the  traces  of  the  disease  become 
less,  until  finally  healthy  children  may  be  begotten. 

The  power  of  hereditary  transmission  peculiar  to  the  mother  depends, 
as  in  the  case  of  the  father,  upon  the  condition  of  the  syphilis  in  her 
organism,  similar  periods  of  latency,  both  spontaneous  and  due  to  mer- 
curials, being  met  with  in  the  female.  If  her  system  at  the  time  of 
conception  is  temporarily  free  from  syphilitic  influence,  her  ovules  are 
capable  of  producing  healthy  children. 

The  number  of  syphilitic  children  which  a  woman  may  produce 
varies.  In  some  cases  of  a  mild  character  healthy  children  may  follow 
the  birth  of  one  or  two  infected  ones.  In  other  cases,  particularly  in 
those  partially  or  entirely  untreated,  there  may  be  six  or  more. 

As  a  rule,  after  the  lapse  of  six  years  the  influence  of  the  disease 
becomes  so  feeble  that  the  risk  of  transmission  is  extremely  slight. 

Infection  of  the  Mother  and  Child  Through  the  Utero-placental 

Circulation. 

There  can  be  no  doubt  that  owing  to  the  loss  of  the  normal  filtrative 
power  of  the  placenta  a  foetus  which  inherits  its  disease  from  a  syphilitic 
father  may,  in  a  greater  or  less  degree,  infect  its  mother,  and  that  a 
mother  infected  with  syphilis  after  the  conception  of  a  healthy  child 
may  transmit  that  disease  to  her  offspring. 

In  support  of  these  well-known  facts  we  can  offer  only  hypotheses, 
which,  however,  are  based  on  strong  analogical  evidence.  It  is  the  rule 
that  the  placenta  acts  as  a  very  perfect  filter,  and  wholly  prevents  the 
passage  of.  solid  particles  of  matter.  If  Ave  assume  that  the  products 
of  syphilitic  infection  are  ptomains  or  toxins  which  are  soluble,  and  of 
tissue-elements  which  are  solid  particles,  the  deduction  may  be  made 
that  in  the  pregnant  woman  there  is  a  continuous  interchange  of  serum 
between  her  and  her  offspring.  Xow,  if  this  serum  contains  syphilitic 
toxins,  it  is  reasonable  to  conclude  that  the  mother  receives  a  modified 
syphilitic  infection  or  intoxication  ;  she  is,  as  we  may  say,  vaccinated. 
This  condition,  while  in  all  probability  not  rendering  her  syphilitic, 
confers  immunity  to  the  infection.  But  it  is  possible  for  micro-organ- 
isms so  to  damage  the  placenta  by  causing  emboli,  hemorrhages,  and 
endothelial  necroses  that  its  filtering  power  is  in  a  measure  lost,  and 
that  through  it  solid  particles  may  permeate.  If  these  hypotheses  are 
true  in  essence,  the  conclusion  is  warranted  that  in  exceptional  cases  the 
healthy  mother  may  be  infected  by  her  syphilitic  foetus. 

Assuming  that  the  toxin  theory  is  scientifically  true,  we  may  infer 
that  the  pregnant  woman  who  is  infected  with  syphilis  after  conception 
nourishes  her  infant  with  a  serum  more  or  less  rich  in  toxins,  and  that 
in  proportion  to  the  quantity  and  malignancy  of  the  circulating  poison 


INFECTION   OF  THE  MOTHER  AND   CHILD,  ETC.  707 

the  child  is  affected,  and  that  when  it  is  very  intense  death   is   pro- 
duced. 

In  all  probability,  therefore,  the  toxic  principles  of  syphilis  may  be 
conveyed  through  the  uteroplacental  circulation  from  mother  to  foetus, 
and  vice  versa,  and  full  infection  may,  in  rare  cases,  occur  when  the 
filtrative  power  of  the  placenta  has  been  impaired  by  morbid  changes. 

The  mothers  who  bear  syphilitic  children  and  present  no  evidence 
of  infection  may  be  thin  and  pallid  or  healthy  and  robust.  Some 
authors  think  that  they  are  the  bearers  of  a  modified  syphilis,  while 
others  claim  that  they  later  on  may,  and  often  do,  present  tertiary  mani- 
festations. In  all  probability  those  authors  who  claim  that  a  modified 
syphilis  has  been  produced  are  correct.  Though  von  During  emphatic- 
ally says  that  these,  women  are  in  a  latent  tertiary  condition,  and  that 
they  do  later  on  present  undoubted  evidence  of  tertiary  syphilis,  and 
reports  three  cases,  I  think  that  we  have  not  as  yet  a  sufficiency  of 
uncontrovertible  facts  to  allow  us  to  make  magisterial  statements.  "We 
still  need  more  well-  and  long- observed  cases. 

It  is  very  certain,  however,  that  these  women  accpuire  an  immunity 
to  syphilitic  infection  from  others.  On  this  subject  Colles  says  :  "  I 
have  never  witnessed  nor  heard  of  an  instance  in  which  a  child  deriving 
the  infection  of  syphilis  from  its  parents  has  caused  an  ulceration  on 
the  breast  of  its  mother."  Colles's  statement  of  what  he  observed  has 
passed  current  as  Colles's  law.  Von  During  very  happily  formulates 
it  as  follows:  "A  healthy  woman  who,  impregnated  by  a  syphilitic 
man,  has  borne  a  syphilitic  child,  may  be  free  of  all  symptoms  of 
syphilitic  infection,  and  may  at  the  same  time  be  refractory  against  any 
syphilitic  infection." 

Abortion  resulting  from  the  death  of  the  foetus  usually  occurs  about 
the  sixth  month,  while  that  caused  by  infection  of  the  mother  during 
pregnancy  takes  place  somewhat  later.  An  aborted  foetus  is  usually  in 
a  macerated  condition,  the  skin  being  easily  detached  and  the  surface 
having  a  livid  purple  color,  and  various  lesions  will  be  found  in  some 
of  the  viscera.  The  integument  may  show  nothing  characteristic  or 
large  bullae  may  be  found  on  the  soles  and  palms. 

In  syphilitic  children  stillborn  at  term  or  dyiug  soon  after  birth  fre- 
quently no  lesion  of  the  skin  is  found.  The  greater  number  of  syphilitic 
children  born  living  appear  well  nourished  and  perfectly  healthy,  but, 
generally  at  the  end  of  three  weeks,  evidences  of  disease  show  them- 
selves. 


708  HEREDITARY  SYPHILIS. 

LESIONS  OF  THE  PLACENTA. 

The  characteristic  lesions  of  the  placenta  are  changes  in  volume, 
weight,  and  consistency,  and,  microscopically,  the  thick,  plump  form  of 
the  foetal  villosities,  which  is  due  to  the  filling-up  of  the  villous  spaces 
with  an  abundant  proliferation  of  moderately  sized  cells  proceeding  from 
the  bloodvessels,  complicated  with  a  proliferation  of  the  cell-contents 
of  the  villi.  Obliteration  of  the  bloodvessels,  and,  finally,  complete 
destruction  of  the  villi,  ensue.  This  affection  may  appropriately  be 
called  "  Deforming  Proliferation  of  Granulation-cells  of  the  Placental 
Villi." 

DEVELOPMENT  OF  HEREDITARY  SYPHILIS. 

The  first  indication  of  disease  in  a  child  apparently  healthy  at  birth 
is  the  characteristic  snuffling,  which  is  the  cause  of  great  discomfort,  and 
in  some  cases  death  ensues  from  the  obstruction  to  breathing.  Emacia- 
tion may  progress  to  such  an  extent  as  to  leave  the  skin  of  the  body 
loose  and  wrinkled.  The  integument  of  the  face  seems  to  be  drawn 
tight  over  the  bones  and  assumes  an  earthy  sallowness.  The  eyes 
become  prominent,  and  the  juvenile  expression  is  lost,  until  these  children 
come  to  look  like  little  old  men  and  women.  In  some  cases,  however, 
even  of  children  intensely  diseased,  excessive  emaciation  is  not  observed, 
so  that  there  seems  to  be  no  special  relation  between  this  condition  and 
the  activity  of  the  disease.  Simultaneous  with  these  changes  the  child's 
nutrition  suffers,  gastro-intestinal  and  pulmonary  lesions  may  be  devel- 
oped, and  various  skin  eruptions  make  their  appearance. 

Eruptions  of  Hereditary  Syphilis. 

The  principal  eruptions  are — the  erythematous  syphilide,  or  roseola  ; 
the  papular  syphilide ;  the  vesicular,  the  pustular,  the  bullous,  and  the 
tubercular  syphilides  ;  and  a  form  of  furuncle. 

With  certain  modifications  the  features  of  syphilitic  eruptions  in 
infants  are  similar  to  those  in  adults.  In  both  cases  they  appear  in 
crops,  but  in  the  hereditary  disease  the  later  rashes  are  less  symmetrical, 
and  are  likely  to  be  limited  to  particular  regions,  and  the  fever  accom- 
panying an  eruption  in  the  acquired  disease  is  frequently  absent.  Al- 
though their  general  course  is  subacute,  yet  on  account  of  the  activity 
of  cell-growth  and  circulation  in  the  integument  of  infants  the  erup- 
tions are  developed  rapidly  and  tend  to  involve  extensive  surfaces.  It 
may  also  be  noticed  that  such  lesions  as  papules  and  condylomata  are 
less  firm  and  solid  than  similar  ones  in  adults. 


THE  PAPULAR  SYPH1LIDE  AND   CONDYLOMA    LATA.         709 

The  erythematous,  papular,  tubercular,  and  gummatous  eruptions 
are  essentially  the  result  of  syphilitic  processes,  while  all  the  ulcerative 
rashes  are  the  outcome  of  a  symbiosis  of  syphilis  and  pyogenic  bacteria. 

The  Erythematous  Syphilide,  or  Roseola. — This  is  the  most 
frequent  and  earliest  hereditary  eruption,  appearing  about  the  third 
week,  and  often  preceded  or  accompanied  by  coryza,  It  begins  on  the 
lower  part  of  the  abdomen  as  minute  round  or  oval  pink  spots,  which 
at  first  disappear  on  pressure.  It  rapidly  invades  the  trunk,  face,  and 
extremities,  and  is  generally  fully  developed  within  a  week.  The  spots 
then  vary  from  a  third  to  half  an  inch  in  diameter,  assume  a  dull-red 
coppery  hue,  and  no  longer  disappear  on  pressure,  owing  to  pigmenta- 
tion of  the  skin.  In  some  cases,  as  in  adults,  punctse  of  a  deeper  color 
are  seen  on  the  surface  of  the  roseolous  patches,  denoting  the  situation 
of  follicles  around  which  the  hyperemia  is  more  intense. 

The  patches  are  not  usually  elevated,  and  desquamation  is  generally 
absent,  except  in  severe  cases  about  the  hands,  feet,  and  nates,  where  it 
may  be  limited  to  the  margins  of  the  patches,  or  it  may  be  so  extensive 
as  to  resemble  psoriasis.  Sometimes  the  spots  run  together  and  fissures 
form,  either  superficial  or  of  sufficient  depth  to  cause  much  pain. 

The  early  change  of  color  to  a  coppery  hue,  seen  in  irregular  patches 
upon  the  chin,  in  the  folds  of  the  neck,  and  on  the  nates,  where  other 
lesions  frequently  coexist,  is  an  important  diagnostic  feature. 

The  tendency  to  a  circular  form,  so  common  in  acquired  syphilis,  is 
observed  in  later  hereditary  eruptions  more  frequently  than  in  roseola. 

The  eruption  is  sometimes  so  evanescent  and  its  color  so  faint  that  it 
passes  unobserved.  By  attention  to  the  characteristics  mentioned  and 
to  the  history  of  the  patient  the  diagnosis  will  generally  be  sufficiently 
easy. 

The  Papular  Syphilide  and  Condylomata  Lata. — These 
lesions  will  be  described  together  on  account  of  their  pathological 
similarity. 

The  papular  syphilide  may  be  the  first  eruption,  and  not  infre- 
quently it  is  intermingled  with  a  roseola,  or  three  or  four  different 
syphilides  may  be  seen  at  the  same  time  on  one  child.  The  small 
acuminated  papule  of  acquired  syphilis  is  scarcely  ever  seen,  except  in 
a  relapse  or  late  in  the  course  of  the  disease.  Flat  papules,  small  and 
large,  scattered  symmetrically  over  the  body  are  the  common  forms. 
Crescentic  grouping  is  seldom  seen  except  at  a  late  period,  and  then 
only  about  the  joints  and  on  the  extremities.  The  papules,  at  first  dull 
red,  and  then  coppery,  may  have  a  smooth  surface,  or  the  epidermis 
may  exfoliate,  especially  on  the  soles  and  palms. 

In  this  connection  may  be  mentioned  certain  diffuse  infiltrations 
sometimes  observed  which  have  not  yet  been  carefully  described.  When 


710  HEREDITARY  SYPHILIS. 

papules  are  copiously  distributed  upon  the  palms  and  soles  it  may  be 
noted  that  they  increase  rapidly  in  size  and  number  and  fuse  together. 
The  skin  is  of  a  dull-red  color,  much  thickened  and  scaly,  An  entire 
foot  or  hand,  or  the  gluteal  region  from  the  thighs  to  the  top  of  the 
sacrum,  may  be  thus  involved. 

Irritation  from  active  movements  or  from  pressure  often  excites 
fissures  and  ulceration,  which  are  the  cause  of  much  suffering.  This 
condition  may  accompany  any  lesion  of  hereditary  syphilis  ;  its  course 
is  chronic,  and  it  is  not,  as  a  rule,  affected  by  internal  medication.  The 
duration  of  the  hereditary  papular  syphilide  depends  upon  treatment, 
to  which  it  promptly  yields. 

Condylomata  lata  are  simply  modifications  of  the  papular  syphilides, 
due  to  their  situation  between  the  folds  of  skin  or  at  its  junction  with 
mucous  membranes  or  wherever  there  is  moisture.  The  change  in  the 
papule  is  chiefly  hypertrophic,  there  being  no  decided  histological  dif- 
ference between  the  two  forms  of  eruption.  In  size  condylomata  vary  ; 
their  shape  is  governed  by  the  conformation  of  the  parts  upon  which 
they  grow  ;  and  in  color  they  are  usually  grayish-pink  to  dark  brown. 
Their  surface  is  generally  .flat,  sometimes  fissured  and  ulcerated,  when  a 
scanty  offensive  secretion  exudes,  which  may  form  a  thin,  dirty-colored 
crust.  Particularly  in  cachectic  infants  a  false  membrane  may  form, 
which  is  slightly  adherent  and  leaves  a  raw,  bleeding  surface  on 
removal. 

Condylomata  are  among  the  early  and  most  obstinate  of  hereditary 
lesions,  local  measures  appearing  to  have  more  effect  upon  them  than 
internal  medication.  They  vary  greatly  in  number,  and  in  infants  are 
most  frequently  seen  about  the  anus.  A  characteristic  symptom  is  ex- 
hibited when  they  exist  at  each  angle  of  the  mouth,  associated  with 
mucous  patches  in  the  buccal  cavity.  They  are  much  aggravated  by 
neglect  and  want  of  cleanliness,  but  with  proper  care  and  treatment 
they  shrink  and  disappear,  leaving  a  temporary  copper-colored  stain. 

The  Vesicular  Syphilide. — This  rare  form  of  eruption  occurs 
among  the  early  symptoms  in  severe  cases  of  hereditary  syphilis.  It  is 
never  general,  and  is  usually  associated  with  a  pustular  or  bullous  erup- 
tion, and  appears  in  groups  of  vesicles,  closely  and  irregularly  packed 
together,  upon  the  chin  and  about  the  mouth,  upon  the  forearms,  the 
nates,  the  hypogastrium,  or  the  thighs.  It  rarely  shows  a  tendency  to 
relapse. 

The  Pustular  Syphilide. — This  eruption  usually  appears  before 
the  eighth  week  in  children  profoundly  syphilitic,  but  is  not  infre- 
quently seen  in  those  whose  nutrition  is  fair.  The  later  it  appears  the 
more  likely  are  the  pustules  to  be  small,  few,  and  superficial.  It  may 
invade  the  entire  body,  but  is  usually  more  abundant  on  the  thighs,  but- 


THE  BULLOUS  SYPHILIDE.  711 

tocks,  and  face,  while  elsewhere  the  pustules  are  thinly  scattered  and 
irregular. 

The  pustules  vary  from  a  third  of  a  line  to  a  line  in  diameter  at 
their  bases,  and  from  a  third  to  half  of  a  line  in  elevation.  The  deep- 
red  color  of  their  thickened  bases  ends  abruptly  at  their  margins.  They 
may  remain  intact  for  many  days,  and  after  rupture  the  ulcerated  sur- 
face may  or  may  not  become  incrusted.  Especially  about  the  mouth 
there  is  a  tendency  to  grouping  and  the  formation  of  quite  extensive 
patches,  or  the  whole  head  and  face  may  be  thus  involved.  The  crusts 
are  generally  darker  than  those  of  eczema  and  contagious  impetigo, 
and  the  ulceration  beneath  is  deeper.  Itching  and  burning  are  usually 
slight,  but  much  uneasiness  and  even  suffering  may  be  caused  in  certain 
locations,  as  when  pustules  form  on  the  scrotum,  the  buttocks,  or  the 
face.  Groups  of  pustules,  attended  by  much  redness  and  thickening 
of  the  surrounding  skin,  may  form  on  the  palms  and  soles,  and  the 
nails  may  be  destroyed  by  pustules  developed  around  them  or  beneath 
their  free  extremities. 

This  eruption  usually  leaves  no  permanent  trace,  but  in  some  cases 
marked  loss  of  tissue  and  scarring  result,  which  become  less  noticeable 
as  the  child  grows  older.  Sometimes  alopecia  results  from  cicatrices  on 
the  scalp  ;  the  free  border  of  the  lips  or  the  angles  of  the  mouth  may 
be  partially  destroyed. 

Fueuncular  Eruptions. — As  early  as  the  sixth  month  or  as  late 
as  the  third  year  crops  of  furuncles  may  appear,  constituting  the  sole 
symptom  of  hereditary  syphilis  or  associated  with  other  lesions.  If 
symmetrically  arranged,  as  they  usually  are,  they  are  quite  numerous ; 
if  irregularly  distributed,  they  are  few.  They  differ  in  some  respects 
from   ordinary  furuncles. 

Their  bases  are  usually  compact,  well  defined,  and  of  a  dull  coppery- 
red  color.  Their  formation  is  slow  and  without  signs  of  active  inflam- 
mation. They  begin  as  a  small  nodule  in  the  corium,  and  gradually  in- 
crease to  the  size  of  half  a  nutmeg.  A  superficial  ulcer  forms  at  the 
summit  of  the  nodule,  and  a  mass  of  slough  comes  away,  leaving  a  deep 
cavity  with  irregular,  unhealthy  walls  and  everted  discolored  margins, 
which  may  remain  in  a  sluggish  condition  for  many  weeks  or  may  in- 
crease in  dimensions.     The  discharge  is  scanty  and  offensive. 

The  Bullous  Syphilide — Pemphigus. — This  eruption,  some- 
times seen  at  birth  and  sometimes  a  month  or  six  weeks  after  birth,  is 
always  indicative  of  a  severe  form  of  hereditary  syphilis,  and  is  fre- 
quently a  precursor  of  death.  As  regards  its  situation,  it  resembles  the 
pustular  syphilide,  but  the  palms  of  the  hands  and  the  soles  of  the  feet 
are  most  frequently  attacked,  the  lower  extremities  being  most  exten- 
sively involved,  while  upon  the  trunk  the  bullae  are  sparsely  scattered. 


712  HEREDITARY  SYPHILIS. 

Diffuse  infiltration,  ulceration,  and  the  formation  of  fissures  may 
attend  the  development  of  this  eruption  upon  the  thighs  and  buttocks 
and  upon  the  extremities.  It  may  accompany  pustules  and,  less  fre- 
quently, one  or  more  of  the  other  syphilides,  is  generally  copious,  and 
is  always  symmetrical.  The  bulla?  are  developed  rapidly,  and  their  sero- 
purulent  contents  soon  become  purulent.  They  are  surrounded  by  a 
rim  of  thickened  integument  of  a  coppery  color,  and,  unlike  other  forms 
of  pemphigus  in  children,  lack  uniformity  of  shape,  some  being  conical, 
others  rounded,  and  still  others  flattened. 

The  Tubeeculab  Syphilide. — This  lesion,  much  rarer  in  heredi- 
tary than  in  acquired  syphilis,  may  occur  as  early  as  the  sixth  month, 
or  a  second  attack  may  be  met  with  several  years  after  birth.  The 
tubercles  begin  as  deeply  seated  papules  or  as  small  movable  nodules,  in 
the  latter  case  greater  depth  of  tissue  being  involved.  The  skin  soon 
becomes  implicated,  and  a  sharply  defined  tumor,  from  a  quarter  of  an 
inch  to  an  inch  or  more  in  diameter,  results,  which  may  disappear 
leaving  no  trace,  or  it  may  break  down  into  an  ulcer  which  is  very  per- 
sistent and  demands  local  as  well  as  constitutional  treatment. 

Regions  where  the  connective  tissue  is  loose  and  abundant  are  the 
favorite  seat  of  tubercles  of  the  largest  size.  Their  surface  sometimes 
becomes  scaly,  and  the  eruption  then  resembles  psoriasis. 

Gummata  and  Gummatous  Ulcers. — These  lesions  sometimes 
appear  as  early  as  the  third  year,  but  generally  later,  even  as  late  as  the 
twentieth  year.  After  this  period  it  is  not  usual  for  ulcerations  to  have 
the  features  of  hereditary  syphilis,  typical  gummata  having  been  ob- 
served by  me  in  only  one  instance. 

The  course  of  these  lesions  in  hereditary  syphilis  is  similar  to  that  in 
acquired,  and  therefore  needs  no  additional  description. 

A  case  of  symmetrical  gangrene  of  the  extremities  and  ears  has 
been  reported  occurring  in  a  syphilitic  infant,  which  was  cured  by  the 
local  use  of  mercurial  ointment  and  the  administration  of  iodide  of  potas- 
sium. 

Affections  of  the  Mucous  Membranes. 

One  of  the  earliest  and  most  constant  symptoms  of  hereditary 
syphilis  is  coryza,  which  is  due  to  structural  changes  in  the  mucous 
membrane  of  the  nasal  passages.  A  few  days  before  the  appearance  of 
general  manifestations  there  may  appear  a  serous  discharge  from  the 
nostrils,  sometimes  trifling,  sometimes  so  excessive  as  to  impede  respi- 
ration, especially  during  sleep  and  in  the  act  of  nursing.  This  discharge 
is  accompanied  by  the  characteristic  "  snuffling." 

The  nasal  secretion  soon  becomes  purulent,  bloody,  and  very  offen- 
sive, and  causes  swelling  and  excoriation  of  the  alee  nasi  and  upper  lip. 


AFFECTIONS  OF  MUCOUS  MEMBRANES.  713 

Tenacious  crusts  composed  of  the  dried  secretions  form  on  the  inflamed 
surfaces,  causing  much  discomfort.  In  its  mildest  and  rarest  form  this 
affection  is  a  simple  erythema.  Generally,  ulceration  of  the  mucous 
membrane  ensues,  and  not  infrequently  the  disease  progresses  to  the 
bony  structures,  producing  necrosis,  with  perforation  or  even  entire 
destruction  of  the  septum,  followed  by  striking  deformity. 

The  intensity  and  chronicity  of  specific  coryza,  the  limitation  of  the 
disease  to  the  nasal  passages,  and  the  coexistence  of  other  syphilitic 
manifestations  are  sufficient  to  establish  the  differential  diagnosis. 

Mucous  Patches  of  the  Mouth. — In  the  infant  these  lesions 
often  lose  their  characteristic  appearance  quite  early.  At  first  they  con- 
sist of  slightly  elevated  portions  of  mucous  membrane  with  whitish  sur- 
faces and  surrounded  by  erythematous  areola?.  The  pearly  epithelial 
covering  may  be  soon  cast  off,  leaving  a  smooth  red  surface,  slightly 
depressed,  which  may  ulcerate.  The  regular  outline  of  the  round  or 
oval  patches  may  be  lost  and  a  number  coalesce,  thus  involving  a  con- 
siderable extent  of  surface,  which  may  be  superficially  ulcerated,  and  in 
cachectic  subjects  is  often  partially  covered  by  an  extremely  adherent 
false  membrane  of  a  pale-brown  color.  The  patches  frequently  become 
hypertrophied  and  resemble  condylomata  lata. 

In  the  early  course  of  hereditary  syphilis  very  many  distinct  mucous 
patches  may  be  counted ;  at  a  later  period  they  are  less  numerous,  but 
they  show  a  decided  tendency  to  relapse,  having  been  seen  by  me  as  late 
as  the  sixth  year. 

The  most  common  situations  of  this  lesion  are  the  angles  of  the 
mouth,  the  mucous  membrane  lining  the  cheeks,  the  pillars  of  the  fauces 
and  the  tonsils,  the  sides  and  frequently  the  dorsum  of  the  tongue,  and 
also  very  often  the  portions  of  the  gums  adjacent  to  the  teeth.  On 
account  of  the  difficulty  of  pharyngeal  examination  in  young  infants  we 
cannot  state  positively  the  frequency  of  the  invasion  of  this  region. 
There  is  certainly  less  tendency  to  extensive  ulceration  of  the  pharynx 
and  tonsils  in  infants  than  in  adults.  At  the  angles  of  the  mouth  the 
ulceration  is  often  extensive  and  painful. 

The  serous  secretion  of  mucous  patches  is  rather  free,  and  quite  as 
infectious  as  that  of  the  initial  lesion.  Hence  the  necessity  of  their 
early  recognition,  and  of  measures  to  prevent  contagion.  Nursing  at 
the  breast  of  any  one  but  the  mother,  kissing  and  fondling,  must  be 
prohibited,  and  great  care  and  cleanliness  must  be  observed  in  the  use 
of  bottles,  cups,  etc.  The  infection  of  the  nurse  by  a  child  having 
mucous  patches  of  the  mouth  is  particularly  liable  to  occur  in  hospitals 
and  in  lying-in  asylums. 

Only  when  ulceration  exists,  or  when  the  mucous  patches  are  compli- 
cated with  diphtheritic  membrane,  is  their  diagnosis  from   stomatitis, 


714  HEREDITARY  SYPHILIS. 

simple  or  parasitic,  attended  with  difficulty.  In  the  absence  of  distinctive 
evidence  in  the  history  and  on  the  body  of  the  child  our  decision  must 
be  based  on  the  local  appearances.  In  simple  stomatitis  the  inflamma- 
tion is  generally  more  diffuse,  the  whole  tongue  in  particular  being 
much  congested  and  often  covered  with  vesicles,  which  are  not  seen 
in  the  specific  disease.  The  tendency  of  mucous  patches  to  develop 
at  the  angles  of  the  mouth  is  a  valuable  point  in  diagnosis.  In  para- 
sitic stomatitis  the  inflammation  is  less  localized  than  in  the  specific  form, 
the  general  hyperemia  is  greater,  and  the  false  membrane  has  a  whiter 
color  and  a  more  patchy  appearance.  In  both  forms  of  non-specific 
stomatitis  the  sulci  between  the  gums  and  cheeks  and  the  gums  them- 
selves are  often  involved  ;  rarely  in  the  specific. 

The  history  of  the  case,  therefore,  and  the  circumscribed  character 
and  limited  distribution  of  mucous  patches,  will  enable  us  to  make  a 
diagnosis. 

Gummatous  Infiltrations. — These  lesions,  consisting  of  cellular 
infiltration  of  the  mucous  membrane,  are  usually  developed  upon  the 
hard  palate  or  upon  the  posterior  pharyngeal  wall,  when  they  may  be 
mistaken  for  retropharyngeal  abscess.  They  are  rarely  seen  before 
the  third  year  of  life,  and  generally  occur  from  the  sixth  to  the  twelfth. 
The  first  indication  of  their  formation  is  a  reddish  elevation  of  the 
mucous  membrane,  forming  a  round  or  oval  patch  from  half  an  inch  to 
an  inch  and  a  half  in  diameter,  which  increases  in  size  and  in  promi- 
nence until  a  well-defined  tumor  results.  Necrotic  changes  almost  in- 
variably occur  in  the  tumor,  leaving  an  ulcer  with  sharply  cut,  under- 
mined edges  and  tenacious  greenish  secretion,  involving  the  mucous 
membrane  even  to  the  subjacent  bone. 

Their  course  is  chronic,  with  slight  tendency  to  invade  surrounding 
parts.  Upon  the  hard  palate  they  give  little  trouble,  but  upon  the  wall 
of  the  pharynx  they  are  the  source  of  much  suffering  and  inconvenience 
in  swallowing.  The  health  may  be  further  impaired  by  the  copious 
secretions  and  the  noxious  gases  developed.  Repair  of  the  ulceration 
is  followed  by  cicatricial  contractions,  which  on  the  hard  palate  may 
affect  phonation,  and  on  the  wall  of  the  pharynx  may  interfere  with 
deglutition.     The  diagnosis  is  generally  easy. 

In  tuberculous  ulceration  of  the  hard  palate  the  process  is  more 
active  and  less  sharply  limited,  while  other  evidences  of  phthisis  exist. 
Retropharyngeal  abscess  is  much  more  acute  in  its  invasion  and  progress 
than  a  gummy  tumor,  and  in  the  latter  case  signs  of  pre-existing 
syphilitic  lesions  may  be  found.  In  all  cases  the  previous  history  of 
the  patient  must  be  learned. 


AFFECTIONS  OF  THE  LUNGS.  715 

Affections  of  the  Larynx. 

In  the  early  periods  of  hereditary  syphilis  the  larynx  and  upper  air- 
passages  may  be  the  seat  of  simple  hypersemia,  of  mucous  patches,  or 
of  ulceration  involving  the  mucous  membrane,  or  even  the  cartilages,  to 
such  an  extent  as  to  result  in  stenosis. 

Like  gummatous  affections  of  the  pharynx,  those  of  the  larynx 
belong  to  the  late  manifestations  of  the  disease.  Like  them,  also,  their 
course  is  quite  rapid,  and  unless  promptly  checked  they  produce  great 
deformity.  Their  symptoms  are  a  varying  degree  of  hoarseness  and 
even  total  loss  of  voice,  with  difficulty  of  respiration  in  the  more  severe 
cases.     Iodide  of  potassium  in  full  doses  should  be  given. 

Affections  of  the  Lungs. 

Interstitial  cell-proliferation,  complicated  in  some  instances  with 
gummatous  infiltration,  are  the  lesions  usually  found  in  hereditary 
syphilitic  infants. 

When  the  lesions  are  extensive  and  fully  developed  the  lung  is  re- 
duced in  size,  increased  in  consistency,  and  when  cut  is  found  to  be 
firmer  and  less  vascular  than  normal.  Scattered  upon  the  surface  of 
the  lung  and  through  its  substance,  on  the  smaller  vessels  and  bronchi, 
which  are  much  thickened  and  look  like  yellow  cords,  are  numerous 
nodules  of  various  sizes.  The  more  recent  are  small  and  of  a  grayish- 
pink  color ;  the  older  ones  may  be  the  size  of  a  filbert,  are  light  yellow, 
and  when  excised  exude  a  thin  milky  fluid,  while  serum  escapes 
from  the  lung-substance.  The  former  appear  to  be  homogeneous, 
while  the  latter  are  granular  and  may  contain  pus.  The  pulmonary 
pleura,  especially  in  the  vicinity  of  the  nodules,  is  thickened  and  opaque. 

The  entire  lung  is  usually  more  or  less  involved  in  the  morbid 
processes,  though  in  some  cases  the  nodules  may  be  few  and  confined  to 
a  portion  of  a  single  lobe. 

The  first  step  in  the  process  is  evidently  active  congestion,  followed 
by  cell-proliferation  around  the  bronchioles,  and  in  a  less  degree  in  the 
walls  of  the  capillaries,  resulting  in  partial  or  complete  obstruction  of 
their  lumen  and  consequent  destruction  of  the  function  of  the  lung- 
tissue. 

The  nodules,  which  represent  one  or  more  plugged  and  distended 
alveoli,  consist  of  a  mass  of  connective-tissue  cells,  fibrous  tissue,  granu- 
lar debris,  and  perhaps  some  gummatous  tissue.  Like  all  new  growths, 
they  are  liable  to  degeneration,  fatty  or  caseous,  and  may  contain  pus 
in  their  centres.  The  pleural  changes  are  due  to  hypersemia  and  in- 
crease of  fibrous  tissue.     True  gummatous  nodules  have  been  found  by 


716  HEREDITARY  SYPHILIS. 

some  observers.  While  two  forms  of  nodules,  the  gummatous  aud  the 
connective  tissue,  may  exist,  their  gross  and  microscopical  appearances 
are  in  some  cases  so  very  similar  that  it  is  impossible  to  distinguish 
them.  The  gray  hepatization  of  pneumonia  resembles  syphilitic  indu- 
ration, but  may  be  recognized  by  the  greater  succulence  and  less  resist- 
ance of  the  lining  tissue  and  by  the  escape  of  true  pus  on  pressure. 
Owing  to  the  nature  and  extent  of  these  pulmonary  lesions  life  is,  in 
most  cases,  destroyed.  They  may,  however,  exist  in  a  moderate  and 
localized  form  without  such  a  result. 

While  these  changes  usually  take  place  in  intra-uterine  life,  we  may 
find  them  at  any  time  when  the  syphilitic  diathesis  is  active,  but  most 
frequently  within  the  first  eighteen  months  of  life.  They  are  not  at- 
tended by  much  systemic  reaction,  and  may  be  developed  in  any  portion 
of  the  lungs  either  symmetrically  or  unilaterally. 

Recent  investigations  have  clearly  shown  that  in  some  children 
affected  with  hereditary  syphilis  the  lungs  very  frequently  are  the  seat 
of  morbid  change  which  to  the  eye  seems  of  syphilitic  nature,  but  which 
under  the  microscope  is  found  to  be  tuberculous. 

Affections  of  the  Liver. 

The  functional  activity  of  the  liver  in  infancy  renders  it  subject  to 
profound  structural  changes,  which  consist  chiefly  of  connective-tissue 
infiltration. 

The  primary  changes  are  vascular.  The  walls  of  the  vessels  are 
much  thickened,  and  around  the  tunica  adventitia  numerous  nuclei  and 
cells,  with  an  abundance  of  fine  fibrillar  connective  tissue,  are  found. 
The  calibre  of  some  of  the  vessels  is  diminished,  and  that  of  others  is 
entirely  obliterated.  Moreover,  various  stages  of  fatty  degeneration  of 
the  hepatic  cells  are  found.  Increase  of  connective  tissue  is  observed 
in  the  parenchymatous  network  of  the  organ  and  in  the  capsule,  which 
may  be  thickened  either  in  its  entire  extent  or  especially  on  its  upper 
surface.  Adhesions  may  form  between  the  convex  surface  and  the 
diaphragm  or  the  peritoneum  of  the  anterior  abdominal  wall. 

Gummous  hepatitis  in  hereditary  syphilis  is  admitted  by  several 
authors.  There  are  two  forms,  one  consisting  of  numerous  minute 
tumors  scattered  through  the  liver,  called  by  Wagner  miliary  syphiloma  ; 
and  the  other  consisting  of  one  or  more  large  circumscribed  tumors, 
such  as  are  found  in  the  adult.  Either  of  these  lesions  may  be  accom- 
panied by  fibroplastic  infiltration. 

In  most  cases  of  liver  syphilis  in  infants  hereditarily  infected  the 
diagnosis  may  be  made  from  the  following  symptoms  :  a  deep  wine- 
colored  venous  stasis  and  oedema  of  the  lower  extremities,  often  accom- 
panied  by  pemphigus  ;  ascites,  due   to   mechanical   obstruction   of  the 


LESWNS   OF  THE  PANCREAS.  717 

circulation,  as  in  cirrhosis  :  a  more  or  less  pronounced  chloro-ansemic 
appearance  of  the  face  ;  and  the  presence  in  the  urine  of  albumin  and 
hsematoglobulin.  Vomiting  may  occur,  and  constipation,  alternating 
with  diarrhoea,  has  been  observed.  Icterus,  symptomatic  of  this  affec- 
tion, has  not  been  noticed.  A  fatal  result  commonly  ensues  in  the 
early  weeks  of  the  child's  existence. 

A  case  of  fatal  icterus  is  reported  in  a  newborn  child  whose  mother 
was  syphilitic.  At  the  autopsy  the  liver  was  found  to  be  hypertrophied 
and  the  seat  of  gummata.  Portions  of  tissue  taken  from  the  liver 
and  spleen,  and  some  blood  when  cultivated,  showed  clearly  the  presence 
of  the  proteus  vulgaris.  This  organism  had  infiltrated  the  intracellular 
spaces  of  the  liver. 

Affections  of  the  Spleen. 

In  cachectic  children  and  in  those  in  whom  the  disease  assumes  a 
severe  form  more  or  less  hypertrophy  of  the  spleen  is  sometimes  ob- 
served, usually  during  the  early  stages  of  syphilis.  The  enlargement 
is  rapid,  the  size  of  the  organ  often  being  quadrupled  in  two  or  three 
weeks.  Mercurial  treatment  induces  the  rapid  subsidence  of  the 
condition. 

Although  we  are  ignorant  of  the  pathology,  the  acuteness  of  its  inva- 
sion and  its  rapid  involution  suggest  hyperemia  rather  than  permanent 
cell-growth.  Still,  it  is  quite  possible  that  cellular  hyperplasia  may  take 
place  in  the  spleen  as  it  does  in  the  liver.  The  peritoneum  may  be 
secondarily  attacked  when  the  liver  and  spleen  are  affected. 

Lesions  of  the  Pancreas. 

In  some  rare  cases  the  pancreas  has  been  found  to  be  affected  in 
hereditary  syphilis.  In  the  most  marked  cases  the  organ  was  much 
enlarged,  its  weight  was  doubled,  its  tissue  firm,  and  on  section  it  pre- 
sented a  glistening  white  appearance,  somewhat  like  that  of  scirrhus, 
the  granular  substance  being  very  indistinct.  Under  the  microscope 
the  interstitial  connective  tissue,  especially  between  the  larger  lobules, 
was  found  greatly  increased.  Portions  of  lobules  were  compressed, 
and  their  epithelium  was  atrophied  and  in  a  state  of  fatty  degeneration. 
The  vessels  of  the  interstitial  tissues  were  few  and  their  walls  were 
thickened.  This  extreme  degree  of  the  process  was  observed  in  seven 
cases ;  in  six  the  changes  were  less  perceptible,  and  the  lobules  could 
be  distinctly  seen,  although  the  organ  was  enlarged  and  rather  denser 
than  normal.     The  head  of  the  organ  was  more  altered  than  the  tail. 

It  is  probable  that  this  degeneration  of  the  pancreas  is  one  of  the 
causes  of  gastro-intestinal  disturbances  in  hereditary  syphilis. 


718  HEREDITARY  SYPHILIS. 

Affections  of  the  Kidney. 

Our  knowledge  of  the  condition  of  the  kidney  in  hereditary  syphilis 
is  very  limited.  Lancereaux  states  that  he  has  found  connective-tissue 
proliferation  with  fatty  degeneration  of  the  epithelium  lining  the  tubuli 
uriniferi.  The  organs  were  firm  and  of  a  yellow  color.  Bradley 
reports  the  case  of  a  syphilitic  child  four  months  old,  with  dropsy  and 
albuminuria,  who  was  cured  by  mercurial  treatment. 

The  studies  on  the  pathological  anatomy  of  the  kidney  by  Parrot 
show  that  these  organs  were  studded  with  numerous  tumors  vary- 
ing in  size  from  a  pin's  head  to  a  cherry-stone.  The  smallest  wTere 
white,  and  the  larger  were  yellow  at  their  periphery  and  reddish  in 
their  centre.  In  some  spots  there  was  partial  destruction  of  the  renal 
tissue,  and  there  were  also  infarctions.  The  lesion  consists  of  a  cir- 
cumscribed or  diffuse  infiltration  of  round  embryonic  cells,  with  others 
of  fusiform  shape,  into  the  connective-tissue  framework,  followed  by 
compression  or  destruction  of  the  tubules  and  colloid  degeneration  of 
their  epithelium.  In  the  early  stages  of  this  affection  the  organs  be- 
come much  enlarged,  and  Molliere  reports  a  case  in  which  they  were 
twice  the  normal  size.  Gradual  atrophy  follows  degeneration  of  the 
new  cells,  and  the  organs  may  finally  become  much  reduced  in  size. 

Several  cases  of  paroxysmal  hemoglobinuria  occurring  in  syphilitic 
children  have  been  reported  in  which  active  syphilitic  treatment  pro- 
duced beneficial  results. 

Affections  of  the  Suprarenal  Capsules. 

Lancereaux  has  noted  enlargement  of  these  organs  in  a  large 
number  of  cases.  Yirchow  has  also  observed  it,  and  speaks  of  a  case 
in  which  complete  fatty  degeneration  was  found — a  condition  met  with 
also  by  Hulke.  According  to  Lancereaux,  proliferation  of  young  con- 
nective-tissue cells  in  the  cortical  substance  has  been  found  by  Biiren- 
sprung.  In  a  case  in  which  the  left  suprarenal  capsule  was  enlarged 
and  adherent  to  the  diaphragm  Hennig  found  its  contents  gelatinous. 

Affections  of  the  Intestines. 

The  intestines  are  frequently  the  seat  of  microbic  invasion  early  in 
hereditary  syphilis,  and  from  this  cause  gastric  and  bowel  troubles  are 
developed.     The  intestines  may  be  the  seat  of  structural  change. 

Forster  has  described  a  fibroid  degeneration  of  Peyer's  patches  in  a 
syphilitic  infant  who  died  six  days  after  birth  with  lobular  pneumonia 
and  purulent  bronchitis.  The  glandular  structure  of  the  patches  had 
been  replaced  by  elevated  grayish-red  masses,  with  smooth  surface  and 
yellowish  centre,   composed  of  nuclei,  cells,  and  fibres  of  connective 


AFFECTIONS  OF  THE  TESTICLES  AND   THEIR  APPENDAGES.    719 

tissue.  Similar  observations  have  been  made  by  Eberth,  Roth,  and 
Oser,  who  have  described  an  affection  consisting  of  multiple  circum- 
scribed indurations,  varying  in  size  and  generally  circular,  situated  on  a 
level  with  Peyer's  patches  and  the  solitary  glands,  the  surrounding 
mucous  membrane  being  smooth  and  slate-colored  or  more  or  less  ulcer- 
ated. 

Affections  of  the  Testicles  and  their  Appendages. 

The  most  common  affection  is  orchitis,  and,  while  inflammation  of 
the  epididymis  is  sometimes  observed,  it  is  but  almost  always  as  a  com- 
plication of  orchitis.  Involvement  of  the  vas  deferens  is  uncommon 
with  epididymo-orchitis. 

The  orchitis  begins  slowly  and  insidiously.  No  pain  is  felt  by  the 
child,  and  attention  is  not  called  to  the  diseased  organ  until  its  dimen- 
sions have  become  so  marked  as  to  attract  the  notice  of  the  mother  or 
nurse.  As  usually  seen  in  practice,  the  testis  is  of  the  size  of  a  pigeon's 
egg.  There  is  no  tendency  to  the  development  of  large  tumors.  To 
the  touch  the  swelled  testis  is  firm  (less  hard  and  ligneous  than  in  the 
adult),  indolent,  painless,  and  decidedly  heavy.  It  can  usually  be 
handled  without  causing  pain.  In  some  cases  there  is  concomitant 
hyperemia  of  the  scrotum.  In  rare  instances  the  surface  of  the  tunica 
albuginea  is  uneven,  and  a  sensation  as  if  small  shot  or  split  peas  were 
seated  in  its  superficies  is  conveyed  to  the  touch. 

The  epididymis  may  be  enlarged  in  part  or  in  whole.  The  swelling 
is  smooth  and  firm,  and  pressure  upon  it  sometimes  causes  pain.  The 
enlargement  of  the  vas  is  similar  in  all  respects  to  that  of  the  epididymis. 

These  affections,  uninfluenced  by  treatment,  usually  run  an  uneventful 
course,  and  may  end  in  resolution  or  in  atrophy,  particularly  of  the 
gland-substance.  Fungous  testis,  abscess,  and  necrosis  are  rare  compli- 
cations. 

Hydrocele  is  a  more  frequent  complication  than  has  heretofore  been 
conceded.  It  may  be  slight  or  well  marked.  Its  existence  in  the 
infant  should  always  excite  suspicion,  since  its  origin  in  syphilis  or 
tuberculosis  is  usually  constant. 

Diagnosis. — As  a  rule,  intelligent  study  of  a  case  of  testicular 
lesion  in  a  young  child  will  lead  to  a  correct  diagnosis.  It  is  necessary 
to  obtain  the  history  of  both  father  and  mother,  and  then  that  of  the 
child.  In  the  early  months  of  hereditary  syphilis  it  may  be  possible 
to  gain  a  knowledge  or  observe  a  vestige  or  sequela  of  some  character- 
istic lesion  itself.  In  this  event  the  diagnosis  will  be  easy.  When, 
however,  we  can  obtain  no  information  concerning  the  father  or  mother, 
and  the  child  is  free  from  syphilitic  lesions  or  their  traces,  difficulty 
is  experienced.     Then  we  should  consider  the  character  of  the  tumor, 


720  HEREDITARY  SYPHILIS. 

and  see  whether  it  conforms  to  the  description  given.  Stress  has 
been  laid  on  the  fact  that  in  syphilis  both  testes  are  usually  involved, 
while  in  tuberculosis  commonly  but  one  is  affected.  This,  however, 
cannot  be  accepted  as  a  general  rule,  since  we  not  uncommonly  find  that 
the  syphilitic  affection  is  unilateral.  Then,  again,  too  much  stress  can- 
not be  laid  upon  the  condition  of  the  epididymis  and  vas.  In  syphilis 
these  appendages  may  be  involved  in  whole  or  in  part ;  in  tuberculosis 
it  is  common  to  find  them  much  enlarged  and  sometimes  nodulated. 
When,  therefore,  we  see  a  case  in  which  there  is  a  unilateral  swelling, 
marked  enlargement  of  the  epididymis,  and  perhaps  of  the  vas,  we  may 
suspect  syphilis.  In  all  such  cases  it  is  absolutely  necessary  to  examine 
the  prostate  and  seminal  vesicles  by  rectal  touch,  and  if  they  also  are 
found  to  be  swollen  the  presumption  will  be  warranted  that  the  case  is 
one  of  tuberculosis.  On  the  other  hand,  freedom  of  these  structures 
from  disease  points  in  a  measure  to  the  existence  of  syphilis. 

No  absolute  conclusions  can  be  drawn  from  the  conditions  attending 
the  invasion  of  the  disease.  In  syphilis  the  enlargement  as  a  rule  takes 
place  slowly,  but  sometimes  rapidly.  In  tuberculosis  the  invasion  may 
be  slow  and  insidious  also.  But  it  is  well  to  remember  that  the  most 
common  mode  of  invasion  is  acute  and  rapid,  and  attended  with  marked 
inflammatory  symptoms.  This  condition  is  rarely,  if  ever,  seen  in 
syphilis. 

While,  therefore,  in  most  cases  a  clear  diagnosis  may  be  made, 
instances  will  occur  in  which  it  is  impossible  to  say  whether  the  lesion 
is  syphilitic  or  tuberculous.  Cases  will  be  met  with  in  which  the  syph- 
ilitic history  is  clear  and  the  testicular  symptoms  point  to  that  origin, 
yet  antisyphilitic  treatment  fails  to  produce  resolution.  In  these  cases 
we  observe  what  is  so  common  in  adults — namely,  a  tubercular  infection 
in  a  syphilitic  subject.  This  is  common  in  many  organs  and  tissues, 
notably  the  lungs,  bones,  joints,  meninges,  and  testes.  It  is  always  well, 
therefore,  to  remember  this  frequently  occurring  mixed  infection.  A 
thickened,  indurated,  and  enlarged  vas  is  strongly  indicative  of  tubercu- 
losis. The  same  may  be  said  of  cases  in  which  there  are  multiple  ulcera- 
tions and  adhesions  of  the  scrotum  to  the  testicles. 

It  is  well  to  remember  that  the  testes  of  young  children  are  some- 
times the  seat  of  carcinoma,  encephaloid  cancer,  and  sarcoma.  These 
malignant  growths  are  usually  seen  in  the  first  year  of  life.  They  are, 
as  a  rule,  of  rapid  development,  of  large  size,  and  may  be  accompanied  by 
inguinal  adenopathy  and  usually  more  or  less  pain,  and  always  terminate 
fatally. 

The  pathological  change  in  most  cases  of  syphilis  of  the  testicle  in 
infants  is  round-cell  infiltration.  In  rare  instances  gummatous  infiltra- 
tion may  be  present. 


AFFECTIONS  OF  THE  NAILS.  721 

Treatment. — In  my  experience  the  mixed  treatment  in  full  and 
increasing  doses  is  the  most  efficient  remedy  in  these  testicular  lesions, 
as  it  is  in  the  bone-  and  joint-lesions  of  hereditary  syphilis.  I  have 
been  often  much  surprised  at  the  large  doses  which  infants  can  take 
with  impunity  and  marked  benefit.  This  treatment,  with  intermissions, 
should  be  kept  up  for  at  least  two  or  three  years. 

Locally  much  good  can  be  derived  from  mercurial  inunctions  to  the 
scrotum,  using,  with  great  care  as  to  the  avoidance  of  dermatitis,  white 
precipitate  or  blue  ointment. 

When  the  organ  is  much  destroyed  by  degenerative  processes  abla- 
tion may  be  necessary. 

Affections  of  the  Synovial  Sheaths. 

In  two  cases  of  hereditary  syphilis  under  my  observation  the  extensor 
tendons  of  the  hands  were  involved,  as  indicated  by  marked  fusiform 
swelling  over  the  metacarpal  bones,  of  doughy  consistence,  and  freely 
movable  under  the  skin,  which  was  slightly  distended  and  reddened. 
Its  development  was  rapid  and  associated  with  other  lesions,  particularly 
osseous,  its  subsequent  course  indolent  and  not  appreciably  affected  by 
mercurial  treatment.  In  one  case  cure  resulted  from  the  application  of 
a  compress  over  a  piece  of  mercurial  plaster  after  withdrawal  of  the  fluid 
with  the  hypodermic  needle.  Other  tendinous  sheaths  than  those  of  the 
hands  may  be  affected. 

Affections  of  the  Nails — Onychia. 

The  nails  are  not  so  frequently  involved  in  hereditary  as  in  acquired 
syphilis.  There  are  two  varieties  of  onychia  :  the  ulcerative,  which  is 
the  more  frequent,  and  the  non-ulcerative. 

Ulcerative  onychia  begins  at  the  side  or  base  of  the  nail  as  a  papule 
or  pustule,  which  soon  ulcerates,  the  process  extending  along  the  concave 
base  of  the  nail,  or  along  the  lateral  margins,  and  finally  involving  the 
matrix  of  the  nail,  which  is  soon  cast  off.  The  distal  phalanx  becomes 
very  painful  and  enlarged,  the  finger  resembling  in  shape  an  Indian 
club.  The  thickened  everted  edges  of  the  ulcer,  its  sloughy  base,  and 
sanious  discharge,  and  the  coppery  hue  of  the  surrounding  skin  are 
characteristic. 

This  form  of  onychia  may  be  met  with  alone  or  associated  with 
general  papular  or  ulcerative  eruptions,  and  is  most  frequently  seen 
during  the  first  year  or  two  of  the  child's  life.  In  cases  improperly 
treated  it  may  be  developed  later,  and,  though  its  course  is  generally 
protracted,  it  may  be  shortened  by  appropriate  treatment.  The  nails  of 
the  hands  seem  to  be  more  often  affected  than  those  of  the  feet. 

The  growth  of  a  deformed   and  useless  nail  or  cicatrization  without 

46 


722  HEREDITARY  SYPHILIS. 

a  new  nail  may  be  expected  in  severe  and  protracted  cases  not  subjected 
to  treatment.  In  such  cases  osteitis  of  the  phalanx  may  indicate  ampu- 
tation. The  second  form  of  onychia  is  even  more  chronic  than  the  pre- 
ceding, and  is  a  much  later  manifestation  of  the  disease.  It  begins  as  a 
swelling  of  a  coppery  hue  at  the  base  or  around  the  margins  of  the  nail, 
which  shades  off  into  the  surrounding  parts.  At  the  same  time  the  nail 
loses  its  smoothness  and  gloss,  and  becomes  thickened,  fissured,  and 
brittle.  The  nail  has  a  dirty-white  color,  and  there  is  always  hyperemia 
of  the  matrix  and  the  surrounding  parts,  with  much  deformity  of  the 
phalanx,  which  may  not  be  permanent.  The  nail  may  be  finally 
restored  in  a  perfectly  healthy  state,  and  the  bone  is  usually  not  in- 
volved. 

Affections  of  the  Hair. 

The  features  of  alopecia  in  hereditary  syphilis  are  similar  to  those 
of  the  shedding  form  in  the  acquired  disease.  It  occurs  also  in  connec- 
tion with  dermal  lesions  of  the  scalp,  particularly  pustular.  In  other 
cases  a  dry  condition  of  the  hair  seems  to  be  a  result  of  the  adynamic 
influence  of  syphilis,  rather  than  any  specific  process. 

Affection  of  the  Thymus  Gland. 

Abscess  of  the  thymus  gland  is  of  very  rare  occurrence  in  hereditary 
syphilis.  We  know  nothing  of  the  clinical  history  of  this  affection, 
and  very  little  about  its  pathology. 

Lesions  of  the  Umbilical  Vein. 

Oedmasson  and  Winckel  found  stenosis  of  the  umbilical  vein  in  the 
cords  of  certain  macerated  foetuses  whose  death  was  attributed  to  syph- 
ilis. The  former  was  of  the  opinion  that  it  was  caused  by  the  atheroma- 
tous process.  Birch-Hirschfeld,  who  has  also  observed  this  condition, 
believes  that  it  is  due  to  changes  similar  to  those  occurring  in  the  arteries 
of  the  brain,  as  described  by  Heubner.  Should  future  investigation 
confirm  the  view  of  Hirschfeld,  this  lesion  of  the  umbilical  vein  must  be 
considered  an  important  element  in  causing  the  death  of  the  syphilitic 
embryo. 

Microbic  invasion  of  the  umbilical  cord  may  occur,  and  as  a  result 
septicaemia  may  be  produced. 

Hemorrhagic  Syphilis. 

Hemorrhagic  syphilis  in  infected  infants  is  sometimes  seen  in  the 
form  of  large  and  small  petechia?  and  ecchymoses.  It  may  occur  into 
the  skin  and  mucous  membranes,  and  also  into  the  viscera  and  from 
the  umbilical  vein. 


AFFECTIONS  OF  THE  BONES.  723 

Micro-organisms  in  Hereditarily  Syphilitic  Children. 

Observations  made  by  Kassowitz  and  Hochsinger  show  that  the 
tissues  of  syphilitic  infants  contain  many  micro-organisms.  In  several 
cases  of  infants  who  died  a  few  days  after  birth  the  last-named  observer 
found  streptococci  and  staphylococci  in  the  skin  above  the  Malpighian 
layer,  in  the  vessels,  and  lymphatics.  He  thinks  that  these  microbes 
penetrate  the  skin  and  mucous  membranes  through  lesions  of  continuity 
produced  by  the  infection.  Kassowitz  and  Hochsinger  found  a  chain- 
coccus  in  the  blood,  bones,  and  viscera  of  syphilitic  infants,  but  not  in 
non-syphilitics.  Chotzen  concludes  that  in  some  cases  the  microbes 
enter  the  system  through  the  nasal  mucous  membrane,  which  is  in  an 
inflamed  condition.  They  are  then  carried  by  the  circulation  to  all 
parts  of  the  body.     In  this  manner  septicaemia  may  be  produced. 

Affections  of  the  Lymphatic  Ganglia. 

General  subacute  adenitis,  invariably  present  in  the  early  stages  of 
the  acquired,  is  always  absent  in  hereditary  syphilis,  and  is  an  impor- 
tant feature  in  the  differentia]  diagnosis.  Swelling  of  the  cervical 
ganglia,  which  often  accompanies  active  lesions  in  the  mouth  and 
throat  and  upon  the  scalp,  frequently  results  in  abscess,  particularly 
in  cachectic  children,  when  the  condition  can  be  distinguished  from 
tuberculosis  only  by  the  history  of  the  case  and  by  concomitant  symp- 
toms. 

Affections  of  the  Bones. 

The  bones  are  affected  in  various  ways  by  hereditary  syphilis.  In 
the  early  months  of  infancy  the  morbid  change  is  frequent  in  long  bones 
at  the  junction  of  the  epiphysis  with  the  diaphysis.  In  the  first  years 
of  hereditary  syphilis  the  small  bones  of  the  fingers  and  toes  are  also 
frequently  affected,  while  later  on  a  tendency  to  invasion  of  the  shafts 
of  long  bones  and  of  the  surfaces  of  flat  ones  is  noticed.  We  shall 
therefore  describe  the  diaphyso-epiphyseal  lesion  under  the  name  osteo- 
chondritis syphilitica,  and  the  affection  of  the  long  bones  under  periostitis. 
The  lesions  of  the  bones  of  the  fingers  and  toes  are  somewhat  peculiar 
and  require  a  separate  description. 

Osteochondritis. — This  affection  is  claimed  to  be  one  of  the  most 
constant  manifestations  of  hereditary  syphilis.  It  is  often  the  only  one, 
and  frequently  its  presence  decides  the  syphilitic  nature  of  coexisting 
lesions.  A  knowledge  of  the  fact  that  this  affection  is  exclusively 
caused  by  syphilis  has  been  of  great  service  in  the  study  of  hereditary 
syphilis. 

The  growth  of  a  bone  in  length  takes  place  at  the  extremity  of  the 
shaft,  where  the  epiphysis  is  joined  to  it  by  a  layer  of  cartilage,  and 


724  HEREDITARY  SYPHILIS. 

here  syphilitic  changes  are  most  often  found,  which  interfere  with  the 
normal  development  of  the  bone. 

The  bones  most  commonly  attacked  are  those  of  the  forearm,  the 
leg,  the  arm,  and  the  thigh.  The  clavicle,  sternum,  and  ribs  are  also 
attacked,  as  well  as  the  metacarpal  and  metatarsal  bones.  The  num- 
ber of  bones  involved  varies.  In  stillborn  infants  and  in  those  dying 
soon  after  birth  the  majority  or  even  all  of  the  long  bones  may  be 
aifected.  It  is  exceptional  for  the  victims  of  multiple  bone  lesions  to 
survive,  and  it  is  fair  to  assume  that  the  number  of  bones  attacked 
varies  with  the  intensity  of  the  syphilitic  diathesis. 

In  these  cases  of  osteochondritis  we  find  at  the  diaphyso-epiphyseal 
junction  a  swelling,  which  may  be  visible,  but  in  fat  children  is  often 
imperceptible.  On  palpation  the  bone  is  found  to  be  encircled  by  an 
abruptly  limited  collar  or  ring.  In  some  cases  the  entire  epiphysis  may 
be  expanded,  with  or  without  a  distinct  ring,  at  its  junction  with  the 
shaft.  The  surface  of  these  swellings  and  rings  is  generally  smooth  ;  it 
may  be  slightly  irregular,  but  is  seldom  very  much  ridged.  When  two 
contiguous  bones  are  affected  they  often  seem  to  be  fused.  In  living 
children  the  distal  more  often  than  the  proximal  extremities  have  been 
found  aifected,  and  the  affection  is  generally  symmetrical,  especially  in 
very  young  subjects.  In  some  cases,  particularly  at  the  lower  end  of 
the  humerus  and  at  the  upper  end  of  the  tibia,  the  lesion  does  not  sur- 
round the  bone,  but  is  limited  to  the  segment  of  the  diaphyso-epiphyseal 
junction. 

The  swellings  on  the  clavicle  are  usually  found  at  its  sternal  end, 
and  are  sometimes  of  large  size.  Those  of  the  sternum  are  not  com- 
mon in  very  young  children  ;  lesions  of  the  ribs,  which  occur  at  their 
junction  with  the  costal  cartilages,  are  also  infrequent,  and  are  gen- 
erally not  so  numerous  nor  symmetrical  as  those  of  rickets. 

These  swellings  may  be  developed  slowly  or  rapidly.  They  usually 
remain  in  an  indolent  condition,  causing  little  if  any  pain,  and  inter- 
fering but  slightly  with  the  motion  of  the  joint.  Under  appropriate 
treatment  they  promptly  subside.  The  integument  undergoes  little  if 
any  change,  and  becomes  tense  and  thin  only  when  the  tumors  are 
exceptionally  large.  The  joints  may  be  secondarily  involved  and  become 
the  seat  of  subacute  synovitis,  the  effusion  being  slight  or  extreme. 
Those  most  commonly  attacked  are  the  elbow  and  knee  ;  as  a  rule,  the 
joints  with  short  epiphyses  are  most  liable  to  hyperemia  and  effusion. 
Pressure,  accompanied  by  internal  treatment,  speedily  disperses  the 
joint-swellings,  which  usually  give  rise  to  but  slight  inconvenience. 

Degenerative  changes  sometimes  take  place  in  these  osseous  lesions. 
In  their  mildest  form  they  consist  simply  of  a  superficial  breaking-down 
at  one  part  of  the  swelling.     We  first  observe  fluctuation,  soon  followed 


AFFECTIONS  OF  THE  BONES.  725 

by  ulceration  of  the  skin,  resembling  in  appearance  that  which  occurs 
in  gummy  tumors.  These  necrotic  changes,  however,  may  be  much 
more  active  and  extensive  in  the  bone  than  in  the  cutaneous  ulcer, 
which  shows  little  tendency  to  increase  in  size.  The  epiphysis  may  be 
entirely  separated  from  the  shaft,  and  if  the  superficial  ulcer  is  large  it 
may  be  extruded.  In  most  cases  where  the  destructive  process  is  exten- 
sive the  syphilitic  diathesis  is  intense,  and  a  fatal  termination  ensues. 
In  others,  however,  reparative  changes  of  an  interesting  and  peculiar 
character  occur. 

The  intervening  cartilage  having  been  destroyed,  the  diaphysis  is 
united  to  the  shaft  by  fibres  of  periosteum  only.  This  membrane  be- 
comes much  thickened  and  forms  a  more  or  less  complete  cylinder, 
uniting  the  two  fragments  with  considerable  firmness.  Bony  spiculse 
shoot  from  its  inner  surface  between  the  two  osseous  surfaces,  and 
eventually  bony  union  is  formed.  The  periosteum  continues  thickened 
for  a  long  time,  but  gradually  resumes  its  normal  proportions  as  the 
union  between  the  bones  grows  firmer. 

Periostitis. — While  osteochondritis  occurs  in  early  infancy,  peri- 
ostitis is  a  later  affection,  attacking  the  bones  of  syphilitic  children 
who  have  begun  to  walk.  Whether  the  active  use  of  the  bones  has 
any  influence  in  developing  periosteal  inflammation  we  cannot  say 
positively,  although  its  occurrence  in  the  bones  of  the  leg  renders  this 
view  probable.  In  the  majority  of  cases  the  femur  and  tibia  are  first 
attacked,  sometimes  as  early  as  the  second  year,  but  generally  in  the 
fourth  or  fifth.  When  long  bones  are  involved  thus  early  the  greater 
part  of  the  shaft  usually  suffers.  The  bone  becomes  very  tender,  and 
soon  is  seen  to  be  enlarged  to  twice  or  thrice  its  normal  thickness. 
It  seems  bent  anteriorly,  producing  marked  deformity.  The  fibula  is 
also  sometimes  affected,  and  generally  both  legs  are  attacked.  The 
bones  of  the  forearm  are,  next  to  the  tibia,  most  prone  to  this  lesion. 
The  earlier  it  appears  the  more  likely  is  it  to  involve  both  limbs  sym- 
metrically ;  at  later  periods  it  may  be  unilateral  and  more  localized, 
perhaps  forming  circumscribed  nodes.  The  skull-bones  are  sometimes 
the  seat  of  these  nodes,  which  are  apt  to  be  quite  large  and  multiple. 
In  very  severe  cases  they  sometimes  break  down  and  form  troublesome 
abscesses.  Although  periostitis  usually  occurs  before  the  twelfth  year, 
I  have  seen  it  as  late  as  the  nineteenth  year. 

Dactylitis  Syphilitica. — In  the  early  months  of  hereditary 
syphilis  children  are  often  attacked  by  swelling  of  the  phalanges  and 
of  the  metacarpal  and  metatarsal  bones.  These  lesions  are  of  the  same 
character  as  those  of  acquired  syphilis.  The  condition  is  well  shown 
in  Fie.  162. 


726 


HEREDITA BY  S YPHILIS. 


If  uninfluenced  by  treatment,  the  swellings  run  a  very  chronic 
course,  but  when  treated  early  they  gradually  subside. 

Swelling  of  the  metacarpal  and  metatarsal  bones  usually  occurs  quite 
early  in  hereditary  syphilis,  and  may  coexist  with  dactylitic  enlarge- 
ments. 

Like  all  bone  lesions  of  syphilis,  these  of  the  bones  of  the  hands 
and  feet  may  be  complicated  with  tuberculosis,  and  in  that  event 
antisyphilitic  medication  will  have  little  if  any  effect. 

Fig.  162. 


Dactylitis  syphilitica  in  the  infant. 

The  treatment  of  all  bone  swellings  should  combine  mercury  with 
iodide  of  potassium.  Mercurial  ointment  applied  locally  is  very  bene- 
ficial. 

Deformities  of  the  Teeth. 

The  teeth  sometimes  are  much  changed  in  hereditary  syphilis. 

Hutchinson,  who  first  described  this  affection,  says:  "As  diag- 
nostic of  hereditary  syphilis  various  peculiarities  are  often  presented 
by  the  other  teeth,  especially  the  canines,  but  the  upper  central  incisors 
are  the  test-teeth.  "When  first  cut  these  teeth  are  usually  short,  narrow 
from  side  to  side  at  their  edges,  and  very  thin.  After  a  while  a  cres- 
centic  portion  from  their  edges  breaks  away,  leaving  a  broad,  shallow, 
vertical  notch  which  is  permanent  for  some  years,  but  between  twenty 
and  thirty  usually  becomes  obliterated  by  the  premature  wearing  down 
of  the  tooth.  The  two  teeth  often  converge,  and  sometimes  they  stand 
widely  apart.  (See  Fig.  163.)  In  certain  instances  in  which  the  notch- 
ing is  either  wholly  absent  or  but  slightly  marked  there  is  still  a  pecu- 
liar color  ('  a  dirty  brownish  hue  resembling  that  of  bad  size ')  and  a 
narrow  squareness  of  form,  which  are  easily  recognized  by  the  practised 
eye."     The  first  set  of  teeth  do  not  exhibit  this  malformation. 

Hutchinson's  Teiad. — Hutchinson  further  insists  upon  the   fol- 


TREATMENT  OF  HEREDITARY  SYPHILIS.  727 

lowing  triad  of  morbid  symptoms  as  being  absolutely  diagnostic  of 
quite  well  advanced  hereditary  syphilis  :  ocular  inflammations,  chiefly 
interstitial  keratitis ;  disturbances  of  hearing ;  and  the  above  described 
dental  malformations.     The  association  of  these  three  forms  of  morbid 

Fig. 163. 


Hutchinson's  teeth. 


change  is  found  only  in  cases  of  hereditary  syphilis.  To  this  triad 
also  may  be  added  the  condition  of  general  want  of  development,  in 
which  the  individual   is  of  child-like  stature. 


Affections  of  the  Nervous  System. 

The  affections  of  the  nervous  system  of  hereditary  syphilis  resemble 
in  their  evolution  and  course  those  of  the  acquired  disease  in  the  com- 
plex and  disorderly  association  of  symptoms  and  in  the  frequent  coexist- 
ence of  eye  affections,  such  as  optic  neuritis  and  paralyses  of  one  or 
more  cranial  nerves.  In  the  hereditary  form  the  ocular  lesions  are,  in 
general,  more  complex  and  numerous  than  in  the  acquired  form. 

TREATMENT  OF  HEREDITARY  SYPHILIS. 

Though  the  treatment  of  hereditary  syphilis  is  very  similar  in  many 
particulars  to  that  of  the  acquired  disease,  it  presents  many  divergencies 
and  difficulties,  and  is  not  followed  by  such  uniformly  good  results  as 
are  obtained  in  adults. 

As  a  rule,  the  treatment  of  acquired  syphilis  is  orderly,  while  that  of 
the  hereditary  form  is  very  often  begun  in  doubt  and  uncertainty,  and 
throughout  its  course  is  subject  to  all  manner  of  changes  and  modifica- 


728  HEREDITARY  SYPHILIS. 

tions.  Consequently,  no  specific  data  can  be  laid  down  for  a  general 
methodical  treatment  of  hereditary  syphilis.  It  is  incumbent,  therefore, 
upon  the  physician  to  watch  his  case  continuously,  and  always  to  be 
ready  with  such  measures  of  relief  as  may  be  indicated  by  the  existing 
lesions. 

It  must  be  clearly  understood  by  the  physician,  and  as  clearly  pre- 
sented to  the  parents  or  guardian,  that,  as  a  rule,  at  least  one  year  and 
more — generally  two — are  necessary  for  the  treatment  of  a  syphilitic 
infant.  The  disappearance  of  one  crop  of  manifestations  merely  means 
that  one  stage  of  the  disease  has  been  auspiciously  passed  over.  We 
must  then  keep  on  in  order  to  attenuate  the  severity  of  later  outbursts. 
It  is  always  well,  however,  to  temper  the  activity  of  treatment  by 
proper  intermissions. 

The  most  precocious  evidence  of  hereditary  syphilis  is  the  bullous 
eruption,  and  it  is  always  the  expression  of  profound  systemic  poison- 
ing. This  eruption  brings  up  the  question  of  the  very  earliest  treat- 
ment of  hereditary  syphilis.  For  very  young  infants,  as  a  rule,  some 
mercurial  salt  in  powder  form,  internally  administered,  is  the  one  best 
borne  and  most  commonly  productive  of  good,  if  such  is  attainable. 
For  this  purpose  many  prefer  calomel,  and  they  administer  it  in  doses 
of  -|  to  -Jr  grain  three  times  daily  for  very  young  children.  It  is  well 
to  give  a  small  dose  to  a  very  weakly  child,  and  then  to  increase  it 
as  fast  as  possible.  For  well-nourished  infants  ^  or  ^  grain  may  be 
given. three  times  daily.  Calomel  can  be  rubbed  up  with  a  little  sugar 
of  milk,  and  the  powder  placed  on  the  child's  tongue  before  it  is  put 
to  the  breast.  In  case  of  diarrhoea,  colic,  or  sleeplessness,  a  little 
Dover's  powder  may  be  added  to  the  mercurial  preparation  which  is 
to  be  used.  When  it  is  possible  to  administer  them,  adjuvant  tonics 
should  be  combined  with  the  mercurial.  For  this  purpose  the  sac- 
charated  carbonate  of  iron  is  very  beneficial.  It  is  palatable  and  well 
borne  by  the  stomach,  and  may  often  be  employed  with  marked  benefit, 
particularly  in  children  who  have  reached  their  third  or  fourth  month. 

Calomel  may  be  given  for  a  considerable  time  with  benefit  and  with- 
out deranging  the  stomach  and  bowels.  However,  its  action  should  be 
carefully  watched,  and  if  anaemia  shows  itself  the  drug  should  be 
discontinued. 

Gray  powder  (hydrargyrum  cum  ereta)  is  also  used  by  many.  It  is 
sometimes  quite  efficient  in  its  action,  and  commonly  it  is  less  liable  to 
produce  gastro-intestinal  reaction  than  any  other  mercurial.  Its  use  is 
indicated  in  very  weak  infants  with  a  tendency  to  great  disturbance  of 
the  stomach  and  bowels.  It  is,  however,  not  uniformly  efficacious.  It 
may  be  given  in  doses  of  from  -^  to  ^  of  a  grain  three  times  daily. 


TREATMENT  OF  HEREDITARY  SYPHILIS.  729 

The  protoiodide  of  mercury  has  been  used  in  the  treatment  of  hered- 
itary syphilis  with  more  or  less  benefit  for  many  years. 

In  very  young  children  it  is  well,  if  the  protoiodide  is  used,  to  begin 
with  2V  grain,  which  may  be  increased  according  to  indications.  Though 
it  is  an  efficient  remedy  in  children,  its  use  is  commonly  attended  with 
colic  and  intestinal  derangements,  which  necessitates  the  admixture  of 
powdered  opium  or  Dover's  powder. 

In  administering  these  mercurial  powders  the  physician  should 
always  be  on  the  watch  as  to  their  action  and  as  to  the  condition  of 
the  little  patient.  In  general,  interrupted  courses  of  a  month  or  six 
weeks'  duration  should  be  followed,  during  which  the  child  should  have 
plenty  of  fresh  air  and  every  conceivable  hygienic  benefit. 

By  many  authors  corrosive  sublimate  is  held  in  high  esteem  in  the 
treatment  of  hereditary  syphilis.  It  is  used  chiefly  in  the  very  early 
weeks  of  life  and  throughout  the  first  year.  If  used,  it  is  best  given 
in  the  form  of  Van  Swieten's  liquid  in  combination  with  a  little  milk. 
For  very  young  children  the  dose  of  this  liquid  is  5  to  10  drops  two 
or  three  times  a  day,  which  is  to  be  increased  considerably  for  older 
children. 

Iodide  of  potassium  has  a  rather  limited  sphere  in  the  treatment  of 
hereditary  syphilis.  It  may  be  of  benefit  in  bone,  joint,  and  cerebral 
affections,  and  in  lesions  of  the  eye  and  ear.  The  dose  of  the  iodide  for 
very  young  infants  is  from  ^  to  1  grain,  well  diluted,  three  times  a  day. 
For  children  of  a  year  or  older,  5  grains  or  more  may  be  given  three 
times  daily. 

The  mixed  treatment  is  very  efficient  in  many  cases  of  hereditary 
syphilis,  particularly  of  the  bones  and  viscera,  and  in  syphilitic  sub- 
cutaneous tumors. 

In  addition  to  this  treatment  by  the  mouth,  other  methods  of  using 
mercury  are  employed  in  the  treatment  of  hereditary  syphilis.  As  a 
general  rule,  mercury  by  stomach  ingestion  is  to  be  recommended  for 
the  first  year  of  the  child's  life.  As  it  grows  older  we  can  resort  to 
mercurial  inunctions.  This  method  of  treatment  is  as  efficient  for  the 
infant  and  child  as  for  the  adult,  and  its  administration  to  the  former 
requires  all  the  care  and  circumspection  laid  down  as  necessary  for  the 
latter.  The  inunctions  should  be  given  daily,  using  15  or  20  grains 
of  the  strong  mercurial  ointment,  going  over  the  whole  body  after  the 
plan  already  described.  At  the  same  time  the  child  should  receive 
an  iron  tonic,  and  perhaps  cod-liver  oil.  Should  evidences  of  debility, 
restlessness,  and  sleeplessness,  of  weakness  or  anaemia,  show  themselves, 
the  inunctions  should  be  stopped  at  once.  In  some  cases,  particularly 
in  children  a  year  or  more  old,  the  local  use  of  mercurial  ointment  or 
of    mercurial  plasters  is  productive  of  much    benefit.     The  ointment 


730  HEREDITARY  SYPHILIS. 

may  be  spread  upon  canton-flannel  or  buckskin,  bound  around  the 
child's  body.  By  this  means  mercury  is  absorbed,  and  frequently 
benefit  is  noted,  particularly  in  cases  of  enlarged  liver  or  spleen.  Mer- 
curial inunctions  and  plasters  are  very  effective  in  many  cases  of 
hereditary  bone  and  joint  disease.  In  intracranial  syphilis,  meningeal 
inflammation,  gummy  tumors,  and  hydrocephalus  interims,  this  method, 
particularly  when  combined  with  iodide  of  potassium  given  internally, 
is  often  productive  of  surprising  results.  The  quantity  of  mercurial 
ointment  (50  per  cent.)  for  each  inunction  is  about  15  grains  for  a 
young  child,  and  this  quantity  may  be  increased  to  30  grains  provided 
there  are  no  contraindicating  conditions,  and  that  improvement  is  noted. 
Elsenberg  advises  full  doses  of  the  iodide  internally,  and  the  inunctions 
to  be  pushed  until  slight  gingivitis  or  salivation  is  produced  ;  then  the 
dose  should  be  diminished  or  the  treatment  temporarily  stopped.  It 
may  be  necessary  and  expedient  thus  to  push  this  combination  treat- 
ment, but  it  should  only  be  done  when  the  case  is  under  the  observation 
of  the  physician. 

Hypodermic  injections  of  solutions  of  bichloride  of  mercury  have 
been  used  with  benefit  in  cases  of  stomach  intolerance  and  in  those  in 
which  a  prompt  action  was  necessary.  The  dose  varies  according  to  the 
age  of  the  child,  the  minimum  dose  being  -^  of  a  grain  and  the  maxi- 
mum -|  of  a  grain. 

Baths  of  corrosive  sublimate  are  of  great  benefit  in  some  cases  of 
hereditary  syphilis.  They  should  never  be  relied  upon  as  a  methodical 
treatment.  These  baths  are  particularly  indicated  in  cases  of  the  bullous 
syphilide,  of  syphilitic  roseola,  of  papular  syphilides,  condylomata  about 
the  genitals,  and  in  cases  in  which  there  are  complicating  ulcerations. 
In  children  with  a  thin,  atrophic  skin,  icterus,  and  enlarged  spleen  they 
may  produce  benefit.  The  quantity  of  the  bichloride  to  be  used  varies 
in  different  cases.  Thus  7\  to  30  grains  of  sublimate,  according  to  the 
age  of  the  child,  with  an  equal  quantity  of  chloride  of  ammonium,  dis- 
solved in  a  glass  of  hot  water,  should  be  added  to  7  or  8  gallons  of  warm 
water.  The  child  should  stay  in  this  from  five  to  ten  minutes,  and  then 
should  be  wrapped  up  warmly  and  put  to  bed.  If  erythema  follows 
this  treatment,  the  surface  should  be  dusted  with  infant  powder ;  but 
if  the  reaction  is  severe  and  persistent,  it  may  be  necessary  to  discontinue 
the  baths.  The  efficacy  of  the  treatment  may  be  ascertained  after  three 
or  four  baths.  If  the  general  condition  of  the  child  and  its  lesions  are 
benefited,  they  may  be  continued.  But  signs  of  resulting  depression, 
weakness,  sleeplessness,  and  refusal  of  food  should  cause  their  discon- 
tinuance. The  baths  may  be  given  every  second  day,  or  perhaps  every 
third  or  fourth  day. 

Local  applications  to  the  lesions  of  hereditary  syphilis   should  be 


TREATMENT  OF  THE  SYPHILITIC  FATHER  AND  MOTHER.   731 

similar  to  those  used  in  the  acquired  form  of  the  disease.  The  ulcers  and 
encrusted  surfaces  left  by  the  bullous  syphilide  and  other  eruptions  of  an 
ulcerative  character  should  first  be  washed  with  a  1  or  2  per  cent,  carbolic- 
acid  solution,  and  then  dressed  with  a  zinc  ointment  to  which  2  to  10 
per  cent,  of  calomel  has  been  added.  This  ointment  may  be  used  for 
fissures  about  the  mouth,  nose,  and  anus.  If  a  stimulant  is  admissible, 
10  drops  of  carbolic  acid  may  be  added  to  each  ounce  of  ointment. 

White  precipitate  ointment  and  a  combination  of  protoiodide  of  mer- 
cury and  cold  cream  (10  to  20  grains  to  the  ounce)  may  be  useful  in 
scaling  papular  eruptions,  particularly  of  the  palms  and  soles. 

Rhinitis  maybe  treated  by  the  use  of  dilute  Dobell's  solution,  injected 
slowly  and  carefully  into  the  nostrils  once  or  twice  a  day.  This  may 
be  followed  by  the  application  of  a  solution  of  nitrate  of  silver 
(^-  to  1  grain  to  the  ounce  of  water).  In  some  cases  a  mild  solution  of 
boric  acid  or  of  borax  is  beneficial  in  removing  mucus  and  crusts.  Mild 
solutions  of  nitrate  of  silver  are  necessary  for  mouth  and  lingual  ulcera- 
tions. Condylomata  lata  of  the  genitals  should  be  kept  clean  and  dry, 
and  should  be  dusted  with  a  powder  composed  of  calomel  one  drachm, 
and  powdered  starch  one  ounce.  If  the  condylomata  have  become 
hypertrophic,  they  may  be  carefully  touched  with  a  solution  of  nitrate 
of  silver  (20  grains  to  the  ounce),  or  with  the  ordinary  acetic  acid,  or 
half-strength  carbolic  acid.  When  stimulating  applications  are  made  to 
these  lesions  great  care  should  be  taken  to  prevent  inflammatory  reaction. 

Bone,  joint,  and  fascial  lesions  should  be  treated  with  plasters  formed 
of  strong  mercurial  ointment  and  Lassar's  paste,  of  each  equal  quantities. 
In  the  management  of  hereditary  ocular  arid  aural  affections,  besides  an 
energetic  internal  treatment,  such  local  measures  are  necessary  as  may  be 
indicated  by  the  condition  present. 

In  general,  the  treatment  of  acquired  syphilis  in  infants  and  young 
children  is  the  same  as  that  given  for  the  hereditary  form  of  the  disease. 
In  acquired  syphilis  of  the  young  the  physician  has  less  trouble,  for  he 
usually  is  not  confronted  with  the  atrophic  condition  and  the  tendency 
to  marasmus  which  are  so  common  in  the  hereditary  disease. 

TREATMENT  OF  THE  SYPHILITIC  FATHER  AND  MOTHER. 

It  is  now  well  known  that  men  suffering  from  syphilis  very  fre- 
quently procreate  infected  children  whose  mothers,  unless  infected  by 
some  active  lesion,  may  remain  free  from  the  disease.  Therefore  it  is 
the  duty  of  the  physician  to  explain  to  a  syphilitic  father  that  his  disease 
is  liable  to  infect  his  offspring,  and  to  urge  him  to  avail  himself  of  all 
possible  measures  to  rid  himself  of  it. 

The  management  of  syphilis  in  the  pregnant  woman  requires  of  the 
physician  skill,   care,   and   watchfulness.     As  soon  as  the  chancre  is 


732  HEREDITARY  SYPHILIS. 

diagnosticated  it  should  be  treated  carefully  and  efficiently.  Lesions  of 
any  kind  on  the  genitals  of  the  pregnant  woman  indicate  the  necessity 
for  great  cleanliness.  This  is  especially  necessary  when  chancre  is 
present.  Therefore  frequent  mild  antiseptic  injections  and  ablutions 
should  be  made  to  the  parts,  in  order  to  avoid  complicating  inflam- 
matory conditions.  Then  mercurial  ointment  on  cotton  or  lint  should 
be  applied  continually  to  the  chancre.  Throughout  the  course  of  ges- 
tation this  antisepsis  of  the  external  genitals  should  be  regularly  fol- 
lowed. 

It  is  well  to  institute  a  systematic  inunction  treatment,  with  all  the 
precautions  and  safeguards  spoken  of  in  the  section  upon  this  branch  of 
the  subject.  No  pains  should  be  spared  in  Avatching  the  woman  to  learn 
that  all  goes  well  and  that  the  therapeutic  effect  is  being  obtained.  In 
this  way  course  after  course  of  inunction  should  be  given,  with  proper 
intervals  of  rest,  during  the  whole  period  of  pregnancy.  If  the  treat- 
ment is  carefully  administered  and  the  general  condition  and  surround- 
ings of  the  woman  are  favorable,  there  will  be  no  trouble  in  keeping 
on  to  the  end. 

In  like  manner,  if  admissible,  hypodermic  injections  of  sublimate 
will  be  found  of  especial  benefit.  They  should  be  given  for  a  week  or 
two  at  a  time,  in  the  retrotrochanteric  regions  principally.  One  very 
great  advantage  of  the  inunction  and  of  the  injection  methods  is  that 
the  stomach — so  prone  to  rebel — and  the  intestines  are  spared. 

But  it  often  happens  that  objections  to  these  methods  are  offered,  and 
that  the  condition  of  the  patient  will  not  permit  of  their  employment. 
In  this  event  it  will  be  necessary  to  resort  to  the  solution  of  mercury 
and  potassium  iodide  spoken  of  on  page  680. 


INDEX. 


ABNORMALITIES  of  penis,  264 
Abscess  of   Bartholin's  glands,   treat- 
ment of,  170 
Abscess  of  Cowper's  glands,  141 
treatment  of,  144 
of  follicles  of  urethra,  138 
follicular,  of  prepuce,  gonorrhceal,  134 
of  penis  in  gonorrhoea,  40 
perinephritic,  416 
symptoms  of,  417 
treatment  of,  417 
peri-urethral,  137 
of  prostate,  course  of,  100 
prognosis  of,  102 
symptoms  of,  101 
treatment  of,  102 
of  testis,  118 
Acneform  chancroids,  442 
syphilides,  553 
diagnosis  of,  554 
prognosis  of,  559 
Acquired  syphilis,  464 
Adenitis,  monoganglionic,  523 
polyganglionic,  523 
syphilitic,  524 
diagnosis  of,  524 
treatment  of,  524 
Adenoma  of  bladder,  386 

of  kidney,  422 
Albangin  in  gonorrhoea,  72 
Albuminuria,  hypertrophy  of  prostate  and, 
314 
syphilis  and,  476 
secondary,  535 
in  acute  posterior  urethritis,  52 
Alcoholic  excesses  and  priapism,  269 
Alcoholism  and  syphilis,  473 
Alexander's     operation   for   prostatectomy, 

320 
Alimentary   canal,   affections   of,   in   treat- 
ment of  syphilis,  695 
Alopecia,  syphilitic,  577 
diagnosis  of,  577 
prognosis  of,  577 
treatment  of,  577 
syphilis,  hereditary,  and,  722 
Amyloid  bodies  and  prostatitis,  300 
Analgesia  in  syphilis,  521 

secondary,  531 
Aneurysm,  syphilitic,  658 
Angina  pectoris  in  syphilis,  secondary,  534 
Annular  chancre,  503 

tubercular  syphilide,  610 
Antiblennorrhagics  in  gonorrhoea,  64 
Anus,  chancre  of,  510 


Anus,  chancroids  of,  446 

condylomata  lata  of,  272 
treatment  of,  572 
Aphasia,  syphilitic,  667 

prognosis  of,  667 
Aponeuroses,  syphilis  of,  638 
Arachnoid,  syphilis  of,  661 
Argentamin  in  gonorrhoea,  72 
Argonin  in  gonorrhoea,  72 
Arnott's  probe,  213 
Arteries,  cerebral,  syphilis  of,  662 
Aspiration,  221 

Ataxia,  locomotor,  syphilitic,  667 
Atrophy,  syphilitic,  of  tongue,  620 

of  testis,  353 

and  epididymitis,  119 
Auramine  in  staining  gonococci,  23 
Auto-infection  with  syphilis,  498 
Auto-inoculation  of  chancroids,  435 

BACILLUS  of  syphilis,  482 
Bacteriuria,  430 
nature  of,  430 
sources  of,  430 
treatment  of,  430 
Balanitis,  causes  of,  242 
and  chancre,  245 
chronic,  243 

causes  of,  244 
complications  of,  245 
croupous,  245 
diabetic,  245 
course  of,  243 
diagnosis  of,  246 
diphtheritic,  245 
and  gangrene  of  prepuce,  246 

prognosis  of,  247 
simple,  242 

syphilis  and,  245 
treatment  of,  245 
Banks'  bougies,  189 

Bartholin's  glands,  abscess  of,  treatment  of, 
170 
inflammation  of,  161 
symptoms  of,  162 
Beneque's  sound,  187 
Bifid  penis,  364 
Bigelow's  evacuator,  382 

lithotrite,  382 
Bistoury,  beaked,  213 
Bladder,  adenoma  of,  386 
bar  at  neck  of,  308 
cysts  of,  386 

diverticula  of,  and  hypertrophy  of  pros- 
tate, 308 

733 


7U 


INDEX. 


Bladder,  exstrophy  of,  393 
treatment  of,  393 
fibroma  of,  386 
foreign  bodies  in,  395 
diagnosis  of,  385 
symptoms  of,  395 
treatment  of,  395 
hematuria  from,  428 
hypertrophy   of   muscles  of,  and  hyper- 
trophy of  prostate,  311 
myxoma  of,  386 
papilloma  of,  386 
rupture  of,  393 
diagnosis  of,  394 
treatment  of,  394 
sacculi  of,  and  hypertrophy  of  prostate, 

311 
stone  in,  and  priapism,  268 
trabeculation    of,   and     hypertrophy   of 

prostate,  311 
traumatisms  of,  393 
tuberculosis  of,  389 
diagnosis  of,  390 
symptoms  of,  389 
treatment  of,  391 
tumors  of,  386 
cystoscopy  in,  391 
diagnosis  of,  388 
mixed,  386 

symptoms  of,  387 
treatment  of,  388 
yillous,  386 
Blood  infection  in  syphilis,  494 

in  syphilis,  changes  in,  481 
Bone,  fragility  of,  in  syphilis,  646 
Bones,  cranial,  syphilis  of,  661 
syphilis  of,  641 
hereditary,  723 
Bottini's  incision  of  prostate,  319 

operation   for    hypertrophy   of    prostate, 
319 
Bougies,  acorn-pointed,  189 
Banks',  189 
filiform,  189 
French,  187 
olivary,  flexible,  187 
Bougies-a-boule,  189 

in  chronic  gonorrhoea,  86 
Brain  lesions  of  tertiary  syphilis,  662 

syphilis  of,  662 
Breast,  chancre  of,  516 

suction  of,  syphilitic  infection  from,  496 
Brenner's  cystoscope,  401 
Bronchi,  syphilis  of,  627 
Buboes,  causes  of,  448 
chancroidal,  447 
operation  for,  461 
treatment  of,  461 
diagnosis  of,  449 
in  gonorrhoea,  40 
hyperplastic  or  mixed,  450 
inflammatory,  447 
yarieties  of,  448 
prognosis  of,  450 
suppurating,  448 
treatment  of,  459 
abortive,  460 


Buboes,  virulent,  448 

Buccal  mucous  patches  in  hereditary  syph- 
ilis, 712 

Bulbous  urethritis,  chronic,  74 

Bullous  syphilide,  617 
prognosis  of,  617 
treatment  of,  617 

Bumstead's  retention-catheter,  220 

Bursa?,  gonorrhceal  inflammation  of,  128 
syphilis  of,  639 

pACHEXIA,  mercurial,  694 
\J     of  secondary  syphilis,  528 
Calcification  of  penis,  263 
Calculi  in  kidney,  420 
diagnosis  of,  421 
hsematuria  from,  421 
symptoms  of,  421 
treatment  of,  421 
mulberry,  375 
phosphatic,  377 
preputial,  265 

treatment  of,  265 
of  prostate,  326 
symptoms  of,  326 
treatment  of,  326 
in  ureters,  398 
urethral,  286 
diagnosis  of,  286 
treatment  of,  286 
vesical,  376 

diagnosis  of,  379 
symptoms  of,  378 
treatment  of,  380 
by  litholapaxy,  381 
by  lithotomy,  lateral,  384 
median,  385 
perineal,  384 
suprapubic,  385 
by  lithotrity,  380 
Calculous  pyelitis,  408 

pyelonephritis,  408 
Calculus,  vesical,  and  hypertrophy  of  pros- 
tate, 311 
Cancer  of  penis,  275 
course  of,  276 
diagnosis  of,  279 
etiology  of,  275 
extirpation  of  ganglia  in,  282 
and  inguinal  ganglia,  278 
pathology  of,  279 
prognosis  of,  279 
symptoms  of,  279 
treatment  of,  277 
syphilis  and,  276 
Cantharides  and  priapism,  269 
Carcinoma  of  testis,  359 

treatment  of,  359 
Cardiac  affections,  gonorrhceal,  132 
prognosis  of,  132 
symptoms  of,  132 
treatment  of,  133 
Caries,  syphilitic,  of  larynx,  625 
Casper's  cystoscope,  401 
Castration,  300 

Catarrhal  inflammation  of  prostate,  291 
in  young  subjects,  293 


IXDEX. 


735 


Catarrhal  prostatitis  in  older  subjects,  296 

secretions  of,  299 

symptoms  of,  296 
urethritis  in  boys,  53 
C'athelin's  urine  separator,  403 
Catheter  fever  and  hvpertrophv  of  prostate, 

314 
introduction  of,  197,  198 
retention-,  Bumstead's,  220 

Thompson's,  220 
staff,  tunnelled,  221 
Catheter-life  and   hvpertrophv  of  prostate, 

317 
Catheterization,  retrograde,  216 

of  ureters,  400 
Catheters,  curved  olivary,  for  hypertrophy 

of  prostate,  323 
Mercier's,   for   hvpertrophy   of  prostate, 

322 
Cauliflower  excrescence,  254 
Cerebral  disease  and  priapism,  269 
Cerebrosrjinal  nerves,  syphilis  of,  662 
Chancre,  annular,  503 
of  anus,  510 
of  breast,  516 

chancrous  erosions  and,  515 
diphtheritic,  503 
duration  of,  506 
ecthymatous,  503 
of  external  ear,  514 
of  eyelids,  514 
of  finger,  511 

exulcerated,  511 

fungating,  511 

panaritium,  like,  511 

scaling  papule,  511 

and  svphilis,  495 
follicular,  503 
of  fossa  navicularis,  509 
of  gums,  513 

hard,  condition  of  lymph-spaces  in,  490 
of  vessels  in,  491 

histology  of,  488 

induration  and,  491 

infection  by,  495 

oedema,  indurating,  and,  491 

perivascular  lymph-spaces  in,  490 

structure  of,  4'. hi 
herpetiform,  multiple,  501 
initial,  appearance  of,  500 
of  integument,  510 
of  lips,  512 
mixed,  504 

necrotic  nodule  and,  503 
of  nipples  and  syphilis,  497 
of  os  uteri,  516 
of  palate,  hard,  513 
parchment,  501 
redux,  517 
of  scrotum,  510 
secretion  of,  504 
silverv  spot,  502 
soft,  435 
of  tongue,  512 
of  tonsil,  513 
treatment  of,  518 

by  acetanilid,  519 


Chancre,  treatment  of,  by  antinosin,  519 

by  aristol,  519 

by  black  wash,  518 

by  calomel,  519 

by  europhen,  519 

by  iodoform,  519 

by  mercurial  ointment,  520 

by  nosophen,  519 

by  yellow  wash,  519 
umbilicated,  503 
of  urethra,  508 
of  vagina,  516, 
in  women,  elevated  papule,  515 

extragenital,  514 

genital,  514 

incrusted,  515 

indurated  nodule,  516 

scaling  papule,  515 
tubercle,  515 

ulcus  elevatum,  515 
Chancroidal  buboes,  447,  461 

operation  for,  461 

treatment  of,  461 
lymphangitis,  446 

treatment  of,  522 
paraphimosis,  447 

treatment  of,  459 
phimosis,  446 

by  dorsal  incision,  457 
failure  of,  457 

by  lateral  incision,  458 

treatment  of,  456 
Chancroids,  435 
acetanilid,  453 
acneform,  442 
of  anus,  445 
appearances  of,  439 
aristol  in,  453 
auto-inoculation  of,  435 
bacteriology  of,  436 
carbolic  acid  in,  463 
cauterization  of,  451 

actual  cautery  in,  452 
Paquelin's,  452 
curette  in,  454 
development  of,  436 
diagnosis  of,  449 
duration  of,  441 
ecthymatous,  442 
europhen  in, 453 
features  of,  442 
follicular,  442 
formalin  in,  462 
of  frsenum,  446 
iodoform  in,  453 
irrigations  in,  451 
of  meatus,  445 
modes  of  infection,  435 
nitrate  of  silver  in,  abuse  of,  452 
nitric  acid  in,  451 
nosophen  in,  453 
of  os  uteri,  445 
pbagedenio,  445 
prognosis  of,  450 
of  rectum,  445 
repair  in,  141 
resorcin  in,  453 


736 


INDEX. 


Chancroids,  seat  of,  441 
secretions  of,  440 
serpiginous,  444 
of  skin  of  penis,  446 
streptobacillus  and,  437 
subpreputial,  446 
susceptibility  to,  436 
in  syphilitic  subjects,  436 
treatment  of  451 
ulcus  elevatum,  444 
of  vagina,  445 
Chanerous  erosion,  500 
chancre  and,  515 
in  women,  515 
Chordee,  41,  268 
Chorea,  syphilitic,  668 
Choroid,  syphilis  of,  590 

treatment  of,  591 
Chylous  hydrocele,  331 
Ciliary  body,  syphilis  of,  588 
Circumcision  clamps,  235 
forceps,  235 
operation  of,  234 
ritual,  and  syphilis,  497 
Civiale's  urethrotome,  191 
Cock's  operation,  21 6 
Coitus  ab  ore  and  syphilitic  infection,  497 
Coitus,  syphilitic  infection  from,  496 
Colles'  law  and  syphilis,  707 

hereditary,  707 
Condylomata  lata  of  anus,  571 
treatment  of,  571 
hereditary,  709 
of  vulva,  571 
treatment  of,  572 
Congenital   hydrocele   of    tunica   vaginalis 
"testis,  328* 
stricture  of  urethra,  174 

causes  of,  174 
syphilis,  700 
Conjunctiva,  syphilis  of,  684 
Conjunctivitis,     serovascular,     gonorrhoea], 
147 
treatment  of,  148 
Cord,  spermatic,  hsematocele  of,  345 
diffuse,  345 

treatment  of,  345 
encysted,  345 

treatment  of,  345 
hydrocele  of,  339 
diffuse,  339 

treatment  of,  341 
encysted,  338 
treatment  of,  339 
spinal,  gonorrhoea  of,  133 
syphilis  of,  662 

torsion   of,   and    strangulation   of   testis, 
345 
treatment  of,  346 
Cornea,  syphilis  of,  586 

treatment  of,  587 
Corneous  vegetations,  255 
Corpora  cavernosa,  fibroid  sclerosis  of,  266 
etiology  of,  267 
pathology  of,  267 
prognosis  of,  268 
treatment  of,  268 


Corpora  cavernosa,  nodes  of,  651 
Corpus  spongiosum,  fracture  of,  261 
Cowpers  glands,  abscess  of,  141 

treatment  of,  144 
Croupous  balanitis,  245 
Curvature  of  penis,  262 

treatment  of,  263 
Cystic  sarcoma  of  testis,  357 
Cystitis,  370 
etiology  of,  370 
gonorrhceal,  105,  371 
acute,  105 
chronic,  186 
diagnosis  of,  106 
pathology  of,  107 
treatment  of,  107 
microbes  of,  370 
origin  of,  371 
pathology  of,  372 
predisposing  conditions,  371 
prognosis  of,  374 
spermato-,  acute,  108 
chronic,  110 
diagnosis  of,  111 
pathology  of,  112 
prognosis  of,  112 
treatment  of,  113 
symptoms  of,  373 
treatment  of,  107,  374 
tubercular,  371 
Cystoscope,  401 
in  hsematuria,  429 
Leiter's,  391 
Cystoscopy,  391 
Cystotomy,  suprapubic,  385 

in  tumors  of  bladder,  389 
Cysts  of  bladder,  386 
dermoid,  of  testis,  360 
treatment  of,  360 
of  epididymis,  118,  338 
of  kidney,  423 

treatment  of,  423 
of  testis,  338 

DACTYLITIS  syphilitica,  647 
diagnosis  of,  650 
hereditary,  725 

treatment  of,  725 
prognosis  of,  651 
treatment  of,  651 
Deferentitis,  gonorrhceal,  114 
Degeneration  of  vessels,  syphilitic,  658 

gangrene  from,  659 
Dementia,  syphilitic,  668 
Dermoid  cysts  of  testis,  360 

treatment  of,  360 
Diabetes  insipidus,  635 

and  syphilis,  636 
Diabetic  balanitis,  244 

course  of,  244 
Diagnosis  of  acneform  syphilide,  554 
of  balanitis,  246 
of  buboes,  448 
of  cancer  of  penis,  279 
of  chancroids,  449 
of  dactylitis  syphilitica,  650 
of  ecthymaform  syphilide,  558 


INDEX. 


737 


Diagnosis  of  epididymitis,  120 
of  epichdymo-orchitis,  120 

of  erythematous  syphilide,  543 
of  foreign  bodies  in  bladder,  395 
of  gonorrhoea,  53 

of  rectum,  96 
of  gonorrhoeal  cystitis,  106 

ophthalmia,  146 

rheumatism,  129 
of  gumma ta,  late,  604 

of  soft  palate,  620 

of  tongue,  620 
of  hsematocele  of  tunica  vaginalis  testis, 

343 
of  herpes  progenitalis,  251 
of  hydrocele,  328 

and  chronic  hsematocele,  33.4 

congenital,    of  tunica   vaginalis    testis, 
328 

encysted,  338 

and  hernia,  333 
of  hydronephrosis,  419 
of  hypertrophy  of  prostate,  316 
of  kidney  conditions  without  catheteriza- 
tion of  ureters,  400 
of  onychia,  582 
of  pigmentary  syphilide,  565 
of  precocious  gummata,  563 
of  prostatitis,  chronic,  302 
of  pyelitis,  414 
of  pyelonephritis,  414 
of  pyonephrosis,  418 
of  rupia,  617 

of  rupture  of  bladder,  394 
of  seminal  vesiculitis,  111 
of  spermatoycystitis,  111 
of  stone  in  kidney,  421 
of  stricture  of  urethra  in  females,  228 

in  males   183 
of  syphilide,  large  flat  papular,  549 

serpiginous,  615 

tubercular,  611 
of  syphilides,  impetigoform,  555 

miliary,  544 

papular,  544 
of  syphilis,  hereditary,  703 

of  liver,  716 

of  nails,  721 

of  pharynx,  714 

of  testis,  656 
of  syphilitic  adenitis,  524 

alopecia,  577 

epididymitis,  late,  655 

epilepsy,  666 

hemiplegia,  665 

orchitis,  657 
of  tuberculosis  of  bladder.  390 
of  tumors  of  bladder,  386 
of  urethritis,  acute  posterior,  53 
of  varicocele,  363 
of  vegetations,  254 
of  vesical  calculi,  319 

tumors,  388 
Dilatation,  continuous,  209 
gradual,  206 

rapid,  for  stricture  of  urethra,  209 
Diphtheria,  resemblance  of  syphilis  to,  463 

47 


Diphtheritic  balanitis,  246 

chancres,  502 
Dislocation  of  penis,  264 

treatment  of,  264 
Divulsion,    operation    of,    in    stricture    of 

urethra,  217 
Drainage,   suprapubic,  for  hypertrophy  of 

prostate,  318 
Ducrey-Unna  streptobacillus,  437 
Dura  mater,  syphilis  of,  661 

EAR,  chancre  of  external,  513 
syphilis  of,  595 
external,  595 

treatment  of,  596 
internal,  596 

treatment  of,  597 
middle,  595 

treatment  of,  595 
Ecthymaform  syphilide,  556 
deep,  557 
diagnosis  of,  558 
prognosis  of,  558 
superficial,  556 
Ecthymatous  chancre,  503 
Ejaculatory  ducts,  lesions  of,  306 
Electrolysis  in  stricture  of  urethra,  217 

Foil's  operation  of,  218 
Electrothermic    angiotribe    for    varicocele, 

366 
Elephantiasis  and  enlargement  of  penis,  265 
of  genitals,  259 
of  penis,  259 

treatment  of,  259 
of  scrotum,  259 
treatment  of,  259 
Emphysema  of  scrotum,  284 

treatment  of,  284 
Enchondroma  of  testis,  360 
Endocarditis,  syphilitic,  628 
Endometritis,  gonorrhoeal,  154 
Endoscope,  limitations  of,  81 
in  urethritis,  chronic,  81 
use  of,  81,  89 

in  gonorrhoea,  chronic,  92 
English  bougies,  186 

scale  for  urethra,  186 
Enteritis  in  treatment  of  syphilis,  695 
Enuresis,  430 

epidural  injections  in,  431 
treatment  of,  431 
Ephemeral  nephritis,  syphilis  and,  535 
Epicystotomy,  385 
Epididymis,  cysts  of,  118,  338 
gonorrhoeal,  118 

induration  of,  118 
hsematocele  of,  344 
treatment  of,  344 
Epididymitis,  1 1 3 

atrophy  of  testis  and,  119 
causes  of,  119 
chronic,  350 

treatment  of,  352 
diagnosis  of,  120 
double,  114 

and  gangrene  of  scrotum,  118 
general  considerations  of,  113 


738 


INDEX. 


Epididymitis,  hydrocele  and,  119 
neuralgia  of  testis  and,  119 
onset  of,  115 
prognosis  of,  120 
reflex  neuralgias  and,  119 
symptoms  of,  115 
syphilis  of,  late,  653 

diagnosis  of,  655 
from  torsion  of  cord,  346 
Epididymo-orchitis,  113 
causes  of,  119 
diagnosis  of,  1 25 
from  gout,  350 
from  grip,  350 
from  malaria,  349 
from  mumps,  349 
from  muscular  contraction,  348 

treatment  of,  349 
onset  of,  115 
prognosis  of,  120 
from  pyaemia,  350 
from  rheumatism,  350 
from  scarlet  fever,  349 
from  smallpox,  349 
symptoms  of,  115 
from  tonsillitis,  350 
•treatment  of,  121 
from  typhoid  fever,  350 
from  urethral  operations,  347 

treatment  of,  348 
from  whooping-cough,  350 
Epidural  injections  in  enuresis,  431 
Epilepsy,  syphilitic,  665 
course  of,  665 
diagnosis  of,,  666 
grand  mal,  665 
petit  mal,  665 
Epispadias,  283 

treatment  of,  283 
Erectile  tumors  of  penis,  260 
Erythema,  syphilitic,  of  larynx,  567 
of  mouth,  566 
of  tongue,  567 
Erythematous  syphilide,  539 
circinate  form  of,  542 
course  of,  543 
diagnosis  of,  543 
duration  of,  543 
hereditary,  709 
seborrhoea  and,  543 
treatment  of,  544 
Etiology  of  cancer  of  penis,  275 
of  cystitis,  370 
of  fibroid  sclerosis  of  corpora  cavernosa, 

267 
of  gonorrhoea,  37 
in  boys,  54 
of  rectum,  95 
of  herpes  progenitalis,  250 
of  hydronephrosis,  419 
of  priapism,  272 
of  pyelitis,  407 
of  pyelonephritis,  407 
of  tertiary  syphilis,  603 
of  varicocele,  362 

of  vulvovaginitis  in  young  girls,  163 
Evacuator,  Bigelow's,  382 


Exanthemata,  resemblance   of  svphilis  to, 

464 
Exostoses,  syphilitic,  643 
Exstrophy  of  bladder,  393 

treatment  of,  393 
Extirpation  of  penis,  281 
Extravasation  of  urine,  222 
symptoms  of,  223 
treatment  of,  224 
Eye,  motor  nerves  of,  syphilis  of,  592 
treatment  of,  592 
syphilis  of,  584 
Eyelids,  chancre  of,  514 

FALLOPIAN  tubes,  gonorrhoea  of,  163 
syphilis  of,  632 
Fibroid  sclerosis  of  corpora  cavernosa,  266 
etiology  of,  267 
pathology  of,  267 
prognosis  of,  268 
treatment  of,  268 
Fibroma  of  bladder,  386 
of  testis,  359 

treatment  of,  360 
Fibromyomatous  tumors  of  prostate,  308 
Filiere  charrie,  186 
Finger,  chancre  of,  511 
Follicles  of  urethra,  abscess  of,  138 
Follicular  abscess  of  prepuce,  gonorrhceal, 
134 
chancre,  503 
chancroids,  442 
urethritis,  chronic,  73,  78 
Folliculitis  in  female,  treatment  of,  170 
gonorrhceal,  in  women,  160 

treatment  of,  170 
para-urethral,  in  women,  161 
Forceps,  stone-,  curved,  386 
Foreign  bodies  in  urethra,  286 
Fort's  electrolyzer,  218 

operation  for  stricture  of  urethra,  218 
Fossa  navicularis,  chancre  of,  509 
Fracture  of  penis,  261 
prognosis  of,  261 
treatment  of,  261 
Fraenum,  chancroids  of,  446 

shortness  of,  and  phimosis,  230 
French  bougies,  187 

scale  for  urethra,  186 
Freudenberg-Bottini  incision,  319 
Funiculitis,  gonorrhceal,  114 
Furuncular   eruptions   in   syphilis,   heredi- 
tary, 711 

GANGLIA,  extirpation   of,  in  cancer  of 
penis,  282 
lymphatic,  syphilis  of,  deep,  525 
hereditary,  723 
superficial,  525 
tertiary,  525 
Gangrene  of  penis,  274 
prognosis  of,  275 
treatment  of,  275 
paraphimosis  and,  239 
of  prepuce  and  balanitis,  246 
of  scrotum,  285 

epididymitis,  and  118 


INDEX. 


739 


Gangrene  from  syphilitic  degeneration  of 
vessels,  659 
syphilitic,  of  skin,  659 
of  testis,  119 
Gangrenous  ulcers,  syphilis  and,  659 
Genital  organs,  mucous  patches  of,  570 
Genitals,  elephantiasis  of,  259 
Gibson  on  perineal  section  without  a  guide, 

217 
Gingivitis  in  treatment  of  syphilis,  695 
Glands,  Bartholin's,  abscess  of,  161 
inflammation  of,  161 
symptoms  of,  161 
Cowper's,  abscess  of,  141 
Skene's,  inflammation  of,  159 
thymus,  hereditary  syphilis  of,  722 
urethral,  inflammation  of,  159 
vestibulovaginal,  inflammation  of,  160 
Glandular  tumors  of  prostate,  308 
Glycosuria,  late  syphilitic,  634 
Gonitis,  126 
Gonocele,  127 
Gonococcus,  19 
appearance  of,  20 
disappearance  of,  37 
grouping  of,  20 
invasion  of,  24 
acute,  31 
subacute,  27 
of  tissues  by,  24 
morphology  of,  19 

new  stain  for,  in  chronic  gonorrhoea,  23 
position  of,  intercellular,  20 
shape  of,  20 
size  of,  20 
staining  of,  21 
by  auramine,  23 
by  Gram-Roux  method,  22 
by  Schiitz  method,  21 
by  thionin,  23 
Gonorrhoea,  abscess  in,  40 
acute  anterior,  39 

dressings  for  penis  in,  59 
hand-syringe  in,  62 
invasion  in,  31 
irrigation  in,  66 
stage  of,  abortive,  56 

antiblennorrhagics  in,  64 
injections  in,  64 
syringes  in,  62 
symptoms  of,  40 
treatment  of,  57 
posterior,  48 
treatment  of,.  68 
argen famine  in,  72 
argonin  in,  72 
bougie-a-boule  in,  86 
bubo  in,  40 
chronic,  anterior,  73 
author's  syringe  in,  84 
infectiousness  of,  91 
new  stain  for  gonococcus  in,  23 
declining  stage  of,  32 
diagnosis  of,  47 
duration  of,  43 
endoscope  in,  89 
endoscopic  applications  in,  90 


Gonorrhoea,  etiology  of,  37 
examination  of  urine  in,  45 
external,  133 
in  female,  149 

treatment  of,  166 

of  urethra,  149 
treatment  of,  167 
of  Fallopian  tubes,  158 
follicular,  chronic,  88 

cupped  sounds  in,  88 
of  heart,  132 
ichthyargon  in,  72 
instillations  and  irrigations  in,  88 
irrigating  syringe  in,  66 
langpl  in,  72 
in  male,  17 

frequency  of,  17 

general  considerations  of,  17 

predisposing  causes  of,  18 
conditions  of,  18 
mild  course  of,  43 
of  mouth,  97 
of  ovaries,  163 
of  os  uteri,  151 
pathology  of,  77 
pendulous  urethra  of,  87 

treatment  of,  88 
period  of  incubation  of,  31 
of  peritoneum  in  women,  163 
posterior,  acute,  48 
duration  of,  50 
symptoms  of,  48 

chronic,  73 
causes  of,  74 
of  preputial  follicles,  134 
prodromal  stage  of,  39 
protargol  in,  72 
purulent  stage  of,  41 
pyaemia  and,  133 
of  rectum,  96 

diagnosis  of,  97 

etiology  of,  96 

prognosis  of,  97 

treatment  of,  97 
relapses  in,  42 
of  spinal  cord,  133 
subacute,  invasion  of,  27 
treatment  of,  abortive,  56 

fads  in,  69 

Janet's,  71 
two-glass  test  in,  45 

of  urethra  in  women,  treatment  of,  167 
of  uterine  cavity,  treatment  in,  169 
of  uterus,  151 
of  vagina,  155 

treatment  of,  168 
of  vulva,  158 

treatment  of,  167 
Gonorrheal  cardiac  affections,  132 
prognosis  of,  133 
symptoms  of,  133 
treatment  of,  133 
cystitis,  105,  371 

acute,  105 

chronic,  105 

treatment  of,  107 
deferentitis,  114 


740 


INDEX. 


Gonorrhoeal  endometritis,  154 
epididymitis,  113 
follicular  abscess  of  prepuce,  134 
folliculitis  in  women,  160 

treatment  of,  170 
funiculitis,  114 
hydrarthrosis,  126 
induration  of  epididymis,  118 
inflammation  of  bursa;,  125 

of  follicles  of  skin  of  penis,  135 

of  tunica  vaginalis,  117 

of  undescended  testis,  117 
neuralgia  of  testis,  treatment  of,  124 
ophthalmia,  144 

diagnosis  of,  146 

prognosis  of,  145 

treatment  of,  146 
peritonitis  in  male,  131 
causes  of,  131 
symptoms  of,  131 
treatment  of,  131 
phimosis,  232 
pyasmia,  133 
pyelitis,  411 
pyelonephritis,  411 
rheumatism,  124 

causes  of,  125 

complications  of,  128 

course  of,  128 

diagnosis  of,  129 

mono-articular,  127 

onset  of,  125 

parts  involved,  125 

polyarticular,  127 

prognosis  of,  130 

symptoms  of,  125 

treatment  of,  130 
serovascular  conjunctivitis,  147 

treatment  of,  148 
threads,  32 

forms  of,  32 
vaginalitis,  114 

treatment  of,  121 
vulvovaginitis,  164 

course  of,  165 

etiology  of,  165 

in  young  girls,  163 
Gouley's  operation,  212 
Gout,  epididymo-orchitis  from,  350 

and  syphilis,  476 
Gram-Roux  method  of  staining  gonococcus, 

22 
Growths,  horny,  258 
Gumma ta  of  heart,  628 
hereditary,  677 
late,  course  of,  628 
of  mouth,  in  hereditary  syphilis,  679 
pathology  of,  493 
of  pharynx,  622 
precocious,  561 

diagnosis  of,  563 

forms  of,  561 

generalized,  561 

localized,  562 

neurotic,  562 

treatment  of,  563 
of  soft  palate,  620 


Gummata  of  soft  palate,  diagnosis  of,  622 
of  spleen,  631 
syphilitic,  of  larynx,  623 
of  tongue,  618 
diagnosis  of,  620 
Gummatous  infiltration,  stages  of,  603 
osteomyelitis,  644 
osteoperiostitis,  644 
syphilides,  late,  604 

precocious,  561 
ulcer,  604 

hereditary,  700 
Gums,  chancre  of,  513 

HEMATOCELE,  343 
acute,  of  tunica  vaginalis  testis,  343 
diagnosis  of,  343 
treatment  of,  343 
chronic,  and  hydrocele,  diagnosis  of,  334 
of  epididymis,  341 
treatment  of,  341 
and  hernia,  diagnosis  of,  341 
parenchymatous,  344 

treatment  of,  844 
of  spermatic  cord,  346 
diffuse,  346 

treatment  of,  346 
encysted,  346 

treatment  of,  346 
of  testis,  344 

treatment  of,  344 
Hsematuria,  428 
from  bladder,  428 
cystoscope  in,  429 
from  kidney,  429 
from  prostate,  429 
in  pyelitis,  413 
in  pyelonephritis,  413 
resorption  test  in,  429 
from  seminal  vesicles,  429 
sources  of,  429 
from  stone  in  kidney,  420 
and  trumatism,  429 
treatment  of,  429 
from  ureter,  429 
from  urethra,  anterior,  428 
_  deep,  428 
Hair,  hereditary  syphilis  of,  722 
syphilitic  affections  of,  573 
forms  of,  573 
Harris'  segregator,  402 
Harrison's  dilators,  189 

whips,  189 
Hayden's  aspirator,  221 

irrigating  syringe  in  gonorrhoea,  66 
trocar,  221 
Headaches,  syphilitic,  treatment  of,  669 
Heart,  gonorrhoea  of,  132 
gummata  of,  629 
syphilis  of,  628 
symptoms  of,  629 
treatment  of,  629 
Hemiplegia,  syphilitic,  663 
diagnosis  of,  665 
prognosis  of,  665 
Hemorrhage,  hereditary  syphilis  and,  722 
secondary,  535         , 


INDEX. 


741 


Hemorrhoids  and  hypertrophy  of  prostate, 

314 
Hepatitis,  diffuse  syphilitic,  629 

gummatous,  639 
Hereditary  condylomata  lata,  709 
gummata,  712 
gummatous  ulcers,  712 
syphilide,  erythematous,  709 
papular,  709 
pustular,  710 
roseolous,  709 
tubercular,  712 
vesicular,  710 
syphilis,  -164 

and  alopecia,  722 
of  bones,  723 
Colles'  law  and,  707 

von  During  on,  707 
course  of,  702 

deformities  of  teeth  and,  726 
development  of,  708 
eruptions  of,  708 
furuncular  eruptions  in,  713 
gummata  of  mouth  in,  714 
of  hair,  722 
hemorrhage  and,  722 
infectiousness  of,  494 
of  intestines,  718 
of  kidney,  718 
of  larynx,  715 
of  liver,  716 
of  lungs,  715 
of  lymphatic  ganglia,  723 
micro-organisms  in,  723 
of  mucous  membranes,  712 
mucous  patches,  buccal,  in,  714 
of  nails,  721 
of  nervous  system,  727 
of  onychia,  721 
osteochondritis  and,  723 
of  pancreas,  717 
periostitis  and,  725 
severity  of,  700 
source  of  infection  in,  704 
of  spleen,  717 
of  suprarenal  capsules,  718 
symptoms  of,  700 
of  synovial  sheaths,  721 
of  testis,  719 
diagnosis  of,  719 
treatment  of,  721 
of  thymus  gland,  722 
transmission  through  uteroplacental  cir- 
culation, 706 
treatment  of,  727 
of  umbilical  vein,  722 
syphilitic  dactylitis,  725 
treatment  of,  726 
Hernia  and  hydrocele,  diagnosis  of,  333 

and  hypertrophy  of  prostate,  314 
Hernial  sac,  hydrocele  of,  342 

treatment  of,  343 
Herpes  preputial  is,  248 
progenitalis,  248 

and  chancrous  erosion,  501 
course  of,  248 
development  of,  248 


Herpes  progenitalis,  diagnosis  of,  251 
etiology  of,  250 
treatment  of,  252 
in  women,  250 
zoster  in  secondary  syphilis,  539 
Herpetiform  chancre,  multiple,  501 
Horny  growths  of  penis,  257 
Horwitz   on    electrothermic  angiotribe    in 

varicocele,  366 
Hutchinson's  teeth,  526 

triad,  726 
Hyaline  cylinders  and  prostatitis,  300 
Hydatid  cysts  of  kidney,  423 

treatment  of,  423 
Hydrarthrosis,  gonorrhoeal,  126 
Hydrocele,  328 

anomalous  forms  of,  331 
bilocularis,  332 
causes  of,  334 
chylous,  330 
circumscribed,  331 
cystic  sarcoma  and,  334 
diagnosis  of,  332 
diverticular,  332 
encysted,  331 
diagnosis  of,  339 
of  epididymis,  338 
of  testis,  338 
treatment  of,  335 
and  epididymitis,  119,  334 
fluid  character  of,  329 
and    hsematocele,   chronic,   diagnosis   of, 

334 
and  hernia,  diagnosis  of,  333 
of  hernial  sac,  342 

treatment  of,  343 
inversion  of  tunica   vaginalis  testis  for, 
m  338 

light  test  and,  333 
pathology  of,  334 
simple,  330 
of  spermatic  cord,  339 
diffuse,  339 

treatment  of,  341 
encysted,  338 
treatment  of,  339 
and  syphilitic  orchitis,  diagnosis  of,  333 
treatment  of,  335 
by  injections,  336 
palliative,  335 
radical,  337 
by  tapping,  335 
of  tunica  vaginalis  testis,  acquired,  329 
congenital,  328 
diagnosis  of,  328 
Volkmann's  operation  for,  337 
von  Bergmann's  operation  for,  337 
Hydronephrosis,  419 
diagnosis  of,  420 
etiology  of,  419 
prognosis  of,  420 
symptoms  of,  419 
treatment  of,  420 
Hyperplasia  of  lymphatic  ganglia,  525 

of  spleen,  syphilis  and,  534 
Hyperplastic  or  mixed  buboes,  460 
Hypertrophic  onychia,  599 


742 


INDEX. 


Hypertrophy   of   muscles  of   bladder  and 
hypertrojthy  of  prostate,  311  * 

of  prostate  307 

and  albuminuria,  514 
Alexander's  operation  for,  320 
and  bar  at  neck  of  bladder,  308 
Bottini's  operation  for,  319 
and  catheter  fever,  314 
and  catheter-life,  317 
catheters,  curved  olivary,  for,  323 

Herder's,  for,  322 
and  changes  in  urine,  313 
and  degeneration  of  kidneys,  313 
diagnosis  of,  314 
diverticula  of  bladder  and,  311 
examination  in,  instrumental,  315 

physical,  315 
forms  of,  308 
hsernaturia  and,  313 
hemorrhoids  and,  311 
hernia  and,  314 
and  hypertrophy  of  muscles  of  bladder, 

313 
ligation  of  iliac  arteries  and,  321 
orchidectomy  for,  321 
pedunculated  tumors  and,  310 
polyuria  and,  314 
post-trigonal  pouch  and,  309 
prolapse  of  rectum  and,  314 
of  prostate,  symptoms  of,  311 

treatment  of,  operative,  318 
prostatectomy  for,  320 

suprapubic,  320 
prostatotomy  and,  318 

perineal,  318 
residual  urine  and,  309 
retention  of  urine  and,  313,  322 

treatment  of,  322 
sacculi  of  bladder  and,  311 

symptoms  of,  311 
so-called  third  lobe  and,  310 
testicular  affections  and,  314 
trabeculation  of  bladder  and,  311 
treatment  of,  316 

operative,  316 

palliative,  316 
trigonum  and,  309 
tumors  at  vesical  neck  and,  308 
urinary  affections  and,  315 
vasectomy  and,  321 
vesical  bar  and,  308 

calculus  and,  311 
of  syphilitic  ulcerations  of  uterus,  652 
Hypospadias,  282 

treatment  of,  282 
Hysteria  in  secondary  syphilis,  530 

TCHTHYARGONIN  in  gonorrhoea,  72 
A     Impetigoform  syphilide,  555 

course  of,  555 

diagnosis  of,  555 

prognosis  of,  555 
Indurations,  relapsing,  517 

forms  of,  517 
Infantile  penis,  264 

syphilis,  700 
Infectiousness  of  chronic  gonorrhoea,  91 


Inflammation  of  Bartholin's  glands,  161 
symptoms  of,  162 
catarrhal,  of  prostate,  292 
in  young  subjects,  293 
chronic,  of  verumontanum,  288 
prognosis  of,  290 
symptoms  of,  289 
treatment  of,  291 
gonorrhceal,  of  bursa?,  125 

of  follicles  of  skin  of  penis,  135 
of  preputial  follicles,  134 
of  tunica  vaginalis,  114 
of  undescended  testis,  117 
of  malplaced  testis,  1 1 7 

symptoms  of,  117 
of  mouth  in  treatment  of  syphilis,  693 
preputial,  and  phimosis,  230 
of  prostatic  urethra,  288 
of  seminal  vesicles,  acute,  108 
symptoms  of,  108 
chronic,  110 
of  Skene's  glands,  159 
suppurative,  of  kidneys,  415 
syphilitic,  of  larynx,  623 

of  spleen,  621 
of  tonsils  in  secondary  syphilis,  533 
of  ureters,  398 
of  urethral  glands,  159 
of  vas  deferens,  118 
of  vestibulo-vaginal  glands,  160 
Inflammatory  buboes,  447 
varieties  of,  448 
phimosis,  chronic,  230 
stricture,  184 
Inguinal  ganglia  and  cancer  of  penis,  278 
Initial  lesion,  appearance  of,  500 
Insomnia  in  secondary  syphilis,  528 
Instillations  in  chronic  gonorrhoea,  84 
Intestines,  syphilis  of,  632 

hereditary,  718 
Iris,  syphilis  of,  588 
Irrigations  in  chronic  gonorrhoea,  84 

JANET'S  treatment  of  gonorrhoea,  71 
Jaundice  in  secondary  syphilis,  534 
Joints,  syphilis  of,  646 
Justus'  test  in  syphilis,  481 
Juxta-urethral  sinuses,  gonorrhceal,  135 
treatment  of,  136 

KIDNEYS,  adenoma  of,  422 
affections  of,  407 
bimanual  palpation  of,  412 
calculi  in,  420 
diagnosis  of,  421 
hsernaturia  in,  421 
symptoms  of,  421 
treatment  of,  421 
colic  and  stone  in  ureters,  398 
contusions  of,  424 
symptoms  of,  424 
treatment  of,  424 
cvsts  of,  423 
"  hydatid,  423 

treatment  of,  423 
degeneration    of,    and     hypertrophy    of 
prostate,  314 


INDEX. 


743 


Kidneys,  floating,  423 

symptoms  of,  423 

treatment  of,  423 
inflammation  of,  suppurative,  407 
movable,  423 

symptoms  of,  423 

treatment  of,  423 
operations  on,  424 
sarcoma  of,  422 
syphilis  of,  Beer  on,  631 

hereditary,  718 

late,  634 

Wagner  on,  634 
syphilitic  lesions  of,  634 
toxic  effects  of  iodides  on,  697 
traumatism  of,  424 
tumors  of,  422 

symptoms  of,  422 

treatment  of,  422 

varieties  of,  422 
wounds  of,  423 

treatment  of,  423 

IACHRYMAL    apparatus,    syphilis    of, 
1    584 
Langol  in  gonorrhoea,  72 
Larynx,  syphilis  of,  569,  623 
hereditary,  715 
tertiary,  623 
syphilitic  caries  of,  625 
erythema  of,  569 
gummata  of,  624 
inflammation  of,  623 
perichondritis,  624 
ulcerations  of,  624 
superficial,  570 
treatment  of,  570 
Lavage  of  anterior  urethra,  46 
Lenticular  papular  syphilides,  546 
modes  of  distribution,  546 
small,  546 
Lesion,  initial,  structure  of,  488 
Leukaemia  and  priapism,  272 
Lids,  syphilis  of,  584 
Lips,  chancre  of,  512 
Litha?mic  pyelitis,  408 
pyelonephritis,  408 
Litholapaxy  (operation),  381 
Lithotomy,  lateral,  384 
median,  385 
perineal,  384 
suprapubic,  385 
Lithotrite,  Bigelow's,  381 

Chismore's,  384 
Lithotrity,  380 
Liver,  syphilis  of,  630 
diagnosis  of,  630 
forms  of,  630 
hereditary,  716 
prognosis  of,  631 
symptoms  of,  630 
Lobes  of  prostate,   lateral,  enlargement  of, 

308 
Locomotor  ataxia,  syphilitic,  667 
Lungs,  syphilis  of,  627 
Lymphangitis,  chancroidal,  446 
treatment  of,  522 


Lymphangitis,  syphilitic,  522 

treatment  of,  522 
Lymphatic  ganglia,  hereditarv  syphilis  of, 
723 

hyperplasia  of,  525 
Lymphatics,  syphilitic  induration  of,  522 

MACULAE  syphilide,  539 
Maisonneuve-Fliihrer's     urethrotome, 
190 
Malaria,  epididymo-orchitis  from,  349 

and  syphilis,  476 
Malignant  precocious  syphilides,  559 
forms  of,  559 
prognosis  of,  560 
treatment  of,  560 
Malplaced  testis,  inflammation  of,  117 

symptoms  of,  117 
Meatotoniy,  200 
Meatus,  chancroids  of,  445 
stricture  of,  causes  of,  199 
symptoms  of,  200 
treatment  of,  200 
Membranous  urethritis,  55 

treatment,  of,  55 
Micro-organisms  in  hereditary  syphilis,  723 

in  syphilis,  482 
Milia  of  penis,  260 
Miliary  syphilides,  544 

diagnosis  of,  545 
Modes  of  infection  with  syphilis,  496 
Mono-articular     gonorrhoeal     rheumatism, 

126 
Monoganglionic  adenitis,  448 
Morning  drops  and  chronic  gonorrhoea,  76 
Morphology  of  the  gonococcus,  19 
Mouth,  gonorrhoea  of,  97 

gummata  of,  in  hereditary  syphilis,  714 
inflammation  of,  in  treatment  of  svphilis, 

695. 
mucous  patches  of,  566 
syphilitic  erythema  of,  566 
Mucous  membrane,  syphilis  of,  566 

hereditary,  712 
Mumps,  epididymo-orchitis  from,  349 
Muscles,  gummata  of,  638 
syphilis  of,  637 
tumors,  gummatous,  of,  637 
Myocarditis,  syphilitic,  628 
Myositis,  syphilitic,  86 
Myxoma  of  bladder,  637 

N^EVI  of  penis,  261 
Nails,  syphilis  of,  diagnosis  of,  582 
hereditary,  721 
prognosis  of,  582 
treatment  of,  583 
syphilitic  affections  of,  577 
separation  of,  581 
Nasopharynx,    inflammation    of,     in    treat- 
ment of  syphilis,  693 
Necrotic  nodule,  chancre  and,  503 
Nephrectomy,  426 

Nephritis,   ephemeral,   in  secondary  syph- 
ilis, 535 
suppurative,  415 
nature  of,  415 


744 


INDEX. 


Nephritis,  suppurative,  symptoms  of,  415 

treatment  of,  415 
Nephrolithotomy,  426 
Nephropexy,  427 
Nephrorrhaphy,  427 
Nephrotomy,  425 

Nerve  lesions  of  tertiary  syphilis,  662 
optie,  syphilis  of,  652 

treatment  of,  653 
Nerves,  cerebrospinal,  syphilis  of,  662 
motor,  of  eye,  syphilis  of,  593 
treatment  of,  594 
Nervous  system,  syphilis  of,  659 
hereditary,  727 
predisposing  causes  of,  659 
treatment  of,  668 
syphilitic  tumors  of,  663 
Neuralgia,  gonorrhoeal,  of  testis,  treatment 
of,  124 
reflex,  and  epididymis,  119 
and  swelled  testicle,  114 
of  testis  and  epididymis,  119 
Neuroglia  in  syphilis,  493 
Nitze  on  cystoscopic  appearances,  392 
Nodule,  indurated,  in  women,  516 
Nose,  syphilis  of,  569 
treatment  of,  509 

OBESITY  and  phimosis,  233 
CEderna,  indurating,  491 
of  scrotum,  284 
treatment  of,  284 
(Esophagus,  syphilis  of,  625 
Olivary  bougies,  187 
Onychia,  578 
diagnosis  of,  582 
dry,  578 

hereditary  syphilis  and,  721 
hypertrophic,  599 
prognosis  of,  582 
syphilitic,  578 
treatment  of,  583 
Opaline  patches,  567 
Ophthalmia,  gonorrhoeal,  144 
diagnosis  of,  146 
prognosis  of,  145 
treatment  of,  146 
Optic  nerve,  syphilis  of,  592 

treatment  of,  593 
Orbit,  syphilis  of,  584 
Orchidectomv  for  hypertrophy  of  prostate, 

331 
Orchitis,  chronic,  354 
treatment  of,  355 
syphilitic,  656 
diagnosis  of,  657 
and  hydrocele,  diagnosis  of,  333 
treatment  of,  657 
torsion  of  cord  and,  345 
Os  uteri,  chancre  of,  516 
chancroids  of,  445 
gonorrhoea  of,  151 
Osseous  affections,  precocious,  in  secondary 

syphilis,  532 
Ossification  of  penis,  263 
Osteochondritis,  hereditary  syphilis  and,  723 
Osteomyelitis,  gummatous,  642 


Osteoperiostitis,  gummatous,  642 

syphilitic,  642 
Otis'  urethrotome,  192 
Ovaries,  gonorrhoea  of,  163 

syphilis  of,  653 

PALATE,  hard,  chancre  of,  513 
soft,  gummata  of,  620 
diagnosis  of,  622 
Pancreas,  hereditary  syphilis  of,  717 
Papilloma  of  bladder,  386 
Papillomatous  tubercular  syphilide,  611 
Papular  syphilides,  544 
hereditary,  709 
large  flat',  549 

diagnosis  of,  550 
scaling  of  palms,  550 

of  sole,  550 
treatment  of,  552 
lenticular,  550 

modes  of  distribution,  550 
small,  546 
miliary,  544 

diagnosis  of,  545 
large,  544 
small,  544 
Papule,  elevated,  in  women,  515 

scaling,  in  women,  515 
Paraphimosis,  acute,  237 
causes  of,  237 
chancroidal,  447 

treatment  of,  459 
chronic,  238 

treatment  of,  242 
curvature  of  penis  and,  240 
gangrene  and,  239 
mechanism  of,  237 
methods  of  reduction  of,  241 
prognosis  of,  239 
treatment  of,  240 
Paraplegia,  syphilitic,  666 
Parasyphilrtic  affections  of  rectum,  632 
Para-urethral  folliculitis  in  women,  161 
Parchment  chancres,  501 
Parenchymatous  hematocele,  344 

sclerosis  of  tongue,  618 
Pathology  of  cancer  of  penis,  279 
of  cystitis,  372 
of  fibroid  sclerosis  of   corpora  cavernosa, 

267 
of  gonorrhoea,  77 
of  gonorrhoeal  cystitis,  107 
of  gummata.  488 
of  horny  growths  of  penis,  259 
of  hydrocele,  334 
of  pyelitis,  410 

ascending,  410 
of  pyelonephritis,  410 
of  seminal  vesiculitis,  112 
of  spermatocystitis,  112 
of  stricture  of  urethra,  gonorrhoeal,  176- 
of  syphilis,  general,  488 

tertiary,  599 
of  syphilitic  infection,  488 
of  urethritis,  chronic,  77 
Pendulous  urethra,  stricture  of,  201 
treatment  of,  202 


INDEX. 


745 


Penis,  abnormalities  of,  26-1 
abscess  of,  in  gonorrhoea,  40 
absence  of,  265 
amputation  of,  280 
bifid,  264 

calcification  of,  263 
cancer  of,  275 

course  of,  276 

diagnosis  of,  279 

etiology  of,  275 

extirpation  of  ganglia  in,  2S2 

inguinal  ganglia  and,  275 

pathology  of,  279 

prognosis  of,  279 

symptoms  of,  276 

treatment  of,  280 
curvature  of,  262 

treatment  of,  263 
dislocation  of,  264 

treatment  of,  264 
double,  265 

dressings  for,  in  acute  gonorrhoea,  59 
elephantiasis  of,  260 

treatment  of,  260 
extirpation  of,  281 
fracture  of,  261 

prognosis  of,  262 

treatment  of,  262 
gangrene  of,  274 

prognosis  of,  275 

treatment  of,  275 
horns  of,  257 
horny  growths  of,  257 
pathology  of,  258 
treatment  of,  258 
infantile,  264 
milia  of,  260 
naevi  of,  260 
ossification  of,  263 

treatment  of,  264 
rudimentary,  264 
sarcoma  of,  282 

treatment  of,  282 
skin  of,  chancroids  of,  445 

gonorrhreal    inflammation    of    follicles 
of,  135 
tumors  of,  erectile,  260 

fatty,  261 

sebaceous,  260 
varix  of,  260 
Penoscrotal     angle,   stricture  at,  treatment 
of,  206 

urethritis,  chronic,  at,  87 
Pericarditis,  syphilitic,  629 
Perichondritis,  syphilitic,  of  larynx,  624 
Perineal  section,  216 

without  a  guide,  Gibson  on,  217 
Perinephritic  abscess,  401 

symptoms  of,  402 

treatment  of,  402 
Perinephritis,  416 
symptoms  of,  417 
treatment  of,  417 
Perionychia,  diffuse,  579 
non-ulcerative,  579 
syphilitic,  579 

forms  of,  579 


Perionychia,  ulcerative,  579 
Periostitis,  hereditary  syphilis  and,  722 
Peritoneum  in  women,  gonorrhoea  of,  163 
Peritonitis,  gonorrhoea!,  in  male,  131 
causes  of,  131 
symptoms  of,  131 
treatment  of,  132 
Peri-urethral  abscess,  137 
Phagedenic  chancroids,  455 
Pharynx,  gummata  of,  622 

inffammation  of,   in   secondary  syphilis, 

622 
syphilis  of,  622 
diagnosis  of,  623 
symptoms  of,  622 
tertiary,  622 
Phimosis,  acquired,  231 
chancroidal,  446 
treatment  of,  456 

by  dorsal  incision,  456 

failure  of,  456 
by  lateral  incision,  457 
cicatricial,  232 
congenital,  229 

in  infants,  229 
gonorrhoeal,  231 
inflammatory,  chronic,  232 
intrapreputial  lesions  and,  233 
obesity  and,  233 
pouting  chin  and.  231 
preputial  inflammation  and,  533 
scissors,  author's,  439 
shortness  of  frsenum  and,  230 

of  preputial  orifice  and,  232 
treatment  of,  234 
Phlebitis,  syphilitic,  657 
Pigmentary  syphilide,  564 
diagnosis  of,  565 
,  forms  of,  564 
treatment  of,  565 
Pleurisy,  syphilis  and,  533 
Polyarticular  gonorrhoeal  rheumatism,  127 
Polyganglionic  adenitis,  523 
Polymorphism  in  syphilis,  secondary,  537 
Polyuria  and  hypertrophy  of  prostate,  314 
Precocious  gummata,  561 
diagnosis  of,  563 
forms  of,  562 
generalized,  561 
localized,  562 
neurotic,  562 
treatment  of,  563 
syphilides,  malignant,  559 
forms  of,  559 
prognosis  of,  560 
treatment  of,  560 
tertiary  syphilis,  598 
Pregnancy  and  vegetations  of  vulva,  256 
Prepuce,  adherent,  and  priapism,  268 
follicular  abscess  of,  gonorrhreal,  134 
gangrene  of,  and  balanitis,  246 
small,  and  phimosis,  230 
Preputial  calculi,  265 
treatment  of,  265 
follicles,  gonorrhoea]  inflammation  of,  134 
inflammation  and  phimosis,  230 
orifice,  small,  and  phimosis,  230 


746 


INDEX. 


Priapism,  268 

adherent  prepuce  and,  268 
after  spinal  injury,  269 
alcoholic  excesses  and,  269 
cantharides  and,  269 
cerebral  disease  and,  269 
etiology  of,  272 
gonorrhoea  and,  268   , 
leukaemia  and,  272 
prognosis  of,  273 
retention  of  urine  and,  268 
sexual  excesses  and,  269 
spinal  disease  and,  269 
stone  in  bladder  and,  268 
treatment  of,  273 
worms  in  rectum  and,  268 
Primary  syphilis,  522 
Proctitis,  syphilitic,  632 
Prognosis  of  abscess  of  prostate,  102 
of  balanitis,  247 
of  buboes,  450 
of  cancer  of  penis,  279 
of  chancroids,  450 
of  chronic    inflammation    of   verumonta- 

num,  290 
of  cystitis,  374 
of  dactylitis  syphilitica,  651 
of  ecthymaform  syphilide,  558 
of  epididymitis,  120 
of  epididymo-orchitis,  120 
of  fibroid  sclerosis  of  corpora  cavernosa, 

268 
of  fracture  of  penis,  262 
of  gangrene  of  penis,  275 
of  gonorrhoea  of  rectum,  96 
of  gonorrhceal  cardiac  affections,  183 

ophthalmia,  145 

rheumatism,  130 
of  gummata,  late,  608 

of  muscles,  638 
of  hydronephrosis,  420 
of  malignant  precocious  syphilides,  660 
of  onychia,  582 
of  paraphimosis,  239 
of  priapism,  273 
of  prostatitis,  chronic,  333 
of  pyonephrosis.  420 
of  rupia,  617 
of  seminal  vesiculitis,  112 
of  spermatocystitis,  112 
of  syphilide,  bullous,  617 

serpiginous,  615 
of  syphilis,  468 

of  liver,  631 

of  nails,  582 
of  syphilitic  alopecia,  577 

aphasia,  667 

hemiplegia,  664 

paraplegia,  667 

synovitis,  late,  647 
of  urethritis,  acute  posterior,  53 
of  variolaform  syphilide,  556 
of  vegetations,  254 
Prostate,  abscess  of,  course  of,  100 

prognosis  of,  102 

symptoms  of,  100 

treatment  of,  102 


Prostate,  affections  of,  288 
calculi  of,  326 

symptoms  of,  326 

treatment  of,  326 
concretions  of,  300 
congestion  of,  98 

chronic,  99 

treatment  of,  99 

subacute,  99 

symptoms  of,  98 
hematuria  from,  313 
hypertrophy  of,  307 

albuminuria  and,  314 

Alexander's  operation  for,  320 

anatomy  of,  308 

bar  at  neck  of  bladder  and,  308 

Bottini's  operation  for,  319 

catheter  fever  and,  314 

catheter-life  and,  317 

catheters,  curved  olivary,  for,  323 
Herder's,  for,  322 

changes  in  urine  and,  313 

degeneration  of  kidneys  and,  314 

diagnosis  of,  314 

diverticula  of  bladder  and,  311 

drainage  for,  suprapubic,  321 

examination  in,  instrumental,  315 
phvsical,  315 

forms  of,  308 

hsematuria  and,  313 

hemorrhoids  and,  314 

hernia  and,  314 

hvpertrophv  of  muscles  of  bladder  and, 
"311 

ligation  of  iliac  arteries  and,  321 

orchidectomy  for,  331 

pedunculated  tumors  and,  310 

polyuria  and,  314 

post-trigonal  pouch  and,  309 

prolapse  of  rectum  and,  314 

prostatectomy  for,  320 

prostatotomy  and,  318 
perineal,  and,  318 

residual  urine  and,  310 

retention  of  urine  and,  313,  322 
treatment  of,  322 

sacculi  of  bladder  and,  308 

so-called  third  lobe  and,  308 

symptoms  of,  311 

testicular  affections  and,  314 

trabeculation  of  bladder  and,  311 

treatment  of,  316 
operative,  318 
palliative,  316 

trigonum  and,  309 

tumors  at  vesical  neck  and,  310 

urinary  affections  and,  314 

vasectomy  and,  321 

vesical  bar  and,  308 
calculus  and,  313 
inflammation  of,  catarrhal,  292 

in  young  subjects,  293 
malignant  growths  of,  326 
symptoms  of,  327 
treatment  of,  327 
massage  of,  for  chronic  prostatitis,  304 
traumatism  of,  327 


INDEX. 


747 


Prostate,  traumatism  of,  causes  of,  327 

treatment  of,  327 
tuberculosis  of,  324 

symptoms  of,  324 

treatment  of,  324 
tumors  of,  fibromyomatous,  308 

glandular,  308 
Prostatectomy,    Alexander's   operation  for, 

320 
for  hypertrophy  of  prostate,  320 
suprapubic,  320 
Prostatic  urethra,  inflammation  of,  288 
Prostatitis  and  amyloid  bodies,  300 
catarrhal,  in  older  subjects,  296 

secretions  of,  294 

symptoms  of,  295 
chronic,  291 

diagnosis  of,  302 

hyaline  cylinders  and,  300 

massage  of  prostate  and,  304 

prognosis  of,  303 

treatment  of,  303 

urethritis  and,  75 
Prostatorrhoea,  301 
symptoms  of,  301 
Prostatotomy  for  hypertrophy  of  prostate, 

318 
perineal,  for  hypertrophy  of  prostate,  318 
urethral,  319 
Protargol  in  gonorrhoea,  72 
Pseudo-chancre  indure,  syphilis  and,  517 
Pseud  o-gonococcus,  23 
Pustular  syphilides,  653 

hereditary,  710 
Pyaemia,  epididymo-orchitis  from,  350 

gonorrhoea!,  133 
Pyelitis,  ascending,  407 
calculous,  408 

pathology  of,  410 
descending,  408 
diagnosis  of,  414 
from  drugs,  409 
eliminative,  409 
etiology  of,  407 
gonorrhoeal,  408 
hsematuria  in,  413 
infectious,  408 
lithaemic,  .408 
micro-organisms  of,  411 
pathology  of,  410 
traumatic,  409 
treatment  of,  414 
tuberculous,  413 
Pyelonephritis,  ascending,  407 
calculous,  408 
'    pathology  of,  410 
descending,  408 
diagnosis  of,  414 
etiology  of,  407 
gonorrhoeal,  408 
hsematuria  in,  413 
infectious,  408 
lithaemic,  408 
micro-organisms  of,  411 
pyuria  and,  413 
suppurative,  413 
symptoms  of,  413 


Pyelonephritis,  traumatic,  409 

treatment  of,  415 

tuberculous,  409 
treatment  of,  415 
Pyonephrosis,  418 

diagnosis  of,  418 

prognosis  of,  418 

symptoms  of,  418 

treatment  of,  419 
Pyuria  and  pyelitis,  413 

pyelonephritis  and,  413 

RAYNAUD'S  disease,  syphilis  and,  659 
Kenal  tuberculosis,  409 
symptoms  of,  414 
Rectum,  chancroid  of,  445 
gonorrhoea  of,  95 
diagnosis  of,  96 
etiology  of,  95 
prognosis  of,  96 
treatment  of,  96 
prolapse  of,  hypertrophy  of  prostate  and, 

314 
stricture  of,  syphilitic,  632 
syphilis  of,  632 
forms  of,  632 
worms  in,  and  priapism,  268 
Reflex  disturbances  in  secondary  syphilis, 

631 
Retina,  syphilis  of,  590 
Rheumatism,  acute  articular,  in  secondary 
syphilis,  533 
epididymo-orchitis  from,  350 
gonorrhoeal,  124 
cause  of,  125 
complications  of,  128 
course  of,  128 
diagnosis  of,  129 
mono-articular,  127 
onset  of,  125 
parts  involved,  126 
polyarticular,  127 
prognosis  of,  130 
symptoms  of,  125 
treatment  of,  130 
syphilis  and,  476 
secondary,  527 
Rheumatoid  pains  in  secondary  syphilis,  532 
Robinson  on  shape  of  ureters,  395 
Roseolous  syphilide,  hereditary,  709 
Rudimentary  penis,  264 
Rupia,  615 

diagnosis  of,  617 

prognosis  of,  617 

treatment  of,  617 

Rupial  syphilide,  615 

Rupture  of  bladder,  393 

SALIVATION   in  treatment  of   syphilis, 
695 
Sarcoma  of  kidney,  422 
cystic,  and  hydrocele,  334 
of  testis,  357 

treatment  of,  359 
of  penis,  282 

treatment  of,  282 
of  testis,  359 


748 


INDEX. 


Sarcoma  of  testis,  treatment  of,  359 
Scarlet  fever,  epididymo-orchitis  from,  349 
Schiitz's  method  of  staining  gonococcus,  21 
Sclera,  syphilis  of,  586 
treatment  of,  586 
Sclerosis,  fibroid,  of  corpora  cavernosa,  266 
of  tongue,  syphilitic,  618 
parenchymatous,  619 
superficial,  618 
Scrotum,  ablation  of,  for  varicocele,  367 
affections  of,  284 
chancre  of,  510 
elephantiasis  of,  259 
treatment  of,  259 
emphysema  of,  284 
treatment  of,  284 
gangrene  of,  285 

epididymitis  and,  119 
treatment  of,  285 
cedema  of,  284 

treatment  of,  284 
tumors  of,  285 
benign,  285 

treatment  of,  285 
malignant,  285 

treatment  of,  285 
treatment  of,  285 
Sebaceous  tumors  of  penis,  260 
Seborrhcea  and  erythematous  syphilide,  543 
Secondary  syphilis,  527 
Seminal  vesicles,  affections  of,  368 
hematuria  from,  368 
inflammation  of,  acute,  108 

chronic,  110 
tuberculosis  of,  368 
treatment  of,  369 
vesiculitis,  acute,  108 
chronic,  110 
diagnosis  of,  111 
pathology  of,  112 
prognosis  of,  11- 
treatment  of,  113 
Serovascular  conjunctivitis,  gonorrhoeal,  148 

treatment  of,  149 
Serpiginous  chancroids,  445 
syphilide,  612 
course  of,  615 
deep,  6l4 
diagnosis  of,  615 
prognosis  of,  615 
superficial,  613 
treatment  of,  615 
Sexual  excesses  and  priapism,  269 
Skene's  glands,  inflammation  of,  159 
Skin  grafting  and  syphilis,  497 
syphilitic  gangrene  of,  659 
toxic  effects  of  iodides  on,  697 
Small-pox,  epididymo-orchitis  from,  349 
Smokers'  patches,  567 
Soft  chancre,  435 
Sound,  tunnelled,  196 

introduction  of,  196 
Sounds,  Beneque's,  187 
conical  steel,  186 
straight  steel,  187 
Spasmodic  stricture,  185 
Spermatocele,  338 


Spermatocystitis,  acute.  108 
chronic,  110 
diagnosis  of,  11 1 
pathology  of,  112 
prognosis  of,  112 
treatment  of,  113 
Spinal  cord,  gonorrhoea  of,  133 

lesions  of  tertiary  syphilis  in,  600 
disease  and  priapism,  269 
Spleen,  enlargement  of,  in  secondary  syph- 
ilis, 534 
gummata  of,  631 
hyperplasia  of,  syphilis  and,  534 
syphilis  of,  631 
hereditary,  717 
symptoms  of,  632 
syphilitic  inflammation  of,  631 
Stomach,  syphilis  of,  632 
Stomatitis  in  treatment  of  syphilis,  695 
Stone  in  kidney,  420 
Streptobacillus  of  Ducrey,  437 
Stricture  of  large  calibre,  202 
nature  of,  203 
treatment  of,  205 
of  meatus,  causes  of,  199 
symptoms  of,  200 
treatment  fof,  200 
of  pendulous  urethra,  201 

treatment  of,  201 
syphilitic,  of  rectum,  633 
of  ureters,  398 
of  urethra,  172 

anterior,  treatment  of,  205 
causes  of,  174 
complications  of,  182 
congenital,  174 
causes  of,  174 
divulsion  in,  217 
electrolysis  in,  217 
treatment  of,  175 
course  of,  179 
development  of,  179 
examination  of,  191 
instrumental,  193 
in  female,  228 
diagnosis  of,  228 
treatment  of,  228 
gonorrhoeal,  pathology  of,  176 
inflammatory,  184 
rapid  dilatation  for,  209 
retention  of  urine  from,  219 

aspiration  in,  220 
rupture  of,  by  operation,  207 
spasmodic,  185 
symptoms  of,  179 
traumatic,  175 

treatment  of,  175 
treatment  of,  175 
varieties  of,  184 
Subpreputial  chancroids,  446 
Suppurative  nephritis,  415 
nature  of,  415 
symptoms  of,  415 
treatment  of,  415 
Suprarenal  capsules,  hereditary  syphilis  of, 

683 
Swelled  testicle,  114 


INDEX. 


749 


Swelled  testicle,  symptoms  of,  115 
Syme's  operation,  215 
Symptoms  of  abscess  of  prostate,  100 
of  calculi  of  prostate,  376 
of  cancer  of  penis,  276 
of  catarrhal  prostatitis,  295 

in  older  subjects,  296 
of   chronic   inflammation   of  vermnonta- 

num,  288 
of  congestion  of  prostate,  98 
of  contusion  of  kidney,  424 
of  cystitis,  372 
of  epididymitis,  115 
of  epididymo-orehitis,  115 
of  extravasation  of  urine,  222 
of  floating  kidney,  423 
of  foreign  bodies  in  bladder,  395 
of  gonorrhcea,  acute,  40 
posterior,  48 

in  boys,  54 
of  gonorrhoeal  cardiac  affections,  133 

peritonitis  in  male,  131 

rheumatism,  126 
of  hydronephrosis,  419 
of  hypertrophy  of  prostate,  311 
of  inflammation  of  Bartholin's  glands,  161 

of  malplaced  testis,  117 

of  seminal  vesicles,  acute,  108 
of  malignant  growths  of  prostate,  326 
of  movable  kidney,  423 
of  perinephritic  abscess,  416 
of  perinephritis,  416 
of  prostatorrhoea,  301 
of  pyelonephritis,  411 
of  pyonephrosis,  418 
of  stone  in  kidney,  420 
of  stricture  of  meatus,  199 
of  suppurative  nephritis,  415 
of  syphilis  of  heart,  629 

of  liver,  630 

of  pharynx,  622 

of  spleen,  631 

of  trachea,  626 
of  tuberculosis  of  bladder,  389 

of  prostate,  325 

renal,  409 
of  tumors  of  bladder,  386 

of  kidneys,  422 
of  urethral  stricture,  179 
of  urethritis,  catarrhal,  in  boys,  53 

chronic,  76 
of  urinary  fever,  225 
of  varicocele,  363 
of  vesical  calculi,  378 

tumors,  387 
Synovial  sheaths,  hereditary  syphilis  of,  721 
Synovitis  in  secondary  syphilis,  531 
Syphilides,  acneform,  553 

diagnosis  of,  553 

prognosis  of,  553 
bullous,  617 

prognosis  of,  617 

treatment  of,  617 
ecthymaform,  556 

deep,  556 

diagnosis  of,  558 

prognosis  of,  558 


j  Syphilides,  ecthymaform,  superficial,  556 
erythematous,  539 

circinate,  541 

course  of,  543 

diagnosis  of,  543 

duration  of,  543 

forms  of,  540 

hereditary,  709 

of  palms,  541 

peculiarities  of,  539 

seborrhoea  and,  543 

treatment  of,  544 
gummatous,  late,  604 

course  of,  603 

diagnosis  of,  608 

precocious,  561 

prognosis  of,  608 
impetigoform,  555 
lenticular,  546 
macular,  539 

malignant  precocious,  559 
forms  of,  559 
prognosis  of,  560 
treatment  of,  560 
miliary,  544 

diagnosis  of,  546 
papular,  544 

hereditary,  709 

large  flat,  549 

diagnosis  of,  550 
scaling  of  palms,  550 

of  sole,  550 
treatment  of,  552 

lenticular,  546 

modes  of  distribution,  546 
small,  546 
pigmentary ,  563 

diagnosis  of,  565 

forms  of,  563 

treatment  of,  565 
pustular,  563 

hereditary,  710 
roseolous,  hereditary,  709 
rupial,  615 
serpiginous,  613 

course  of,  613 

deep,  6l4 

diagnosis  of,  615 

prognosis  of,  615 

superficial,  613 

treatment  of,  615 
tertiary,  604 
tubercular,  609 

annular,  610 

course  of,  610 

diagnosis  of,  611 

papillomatous,  610 

treatment  of,  612 

vegetating,  610 
variolaform,  556 

prognosis  of,  556 
Syphilis,  4(13 
acquired,  464 
acute  infections  and,  463 
albuminuria  and,  476 
in  alcoholics,  475 
alcoholism  and,  475 


750 


INDEX. 


Syphilis,  analgesia  in,  521 
angina  pectoris  and,  534 
aneurysm  and,  657 
of  aponeuroses,  638 
of  arachnoid,  661 
of  arteries,  cerebral,  662 
from  auto-infection,  498 
bacillus  of,  482 
balanitis  and,  245 
blood  changes  in,  481 
of  bones,  641 

fragility  of,  646 
of  brain,  662 
of  bronchi,  627 
of  bursa?,  637 
cancer  and,  478 
of  cerebrospinal  nerves,  662 
of  choroid,  590 

treatment  of,  591 
chronology  of,  466 
of  ciliary  body,  588 
Colles'  law  and,  459 
in  communion  cups,  498 
complications  of,  474 
congenital,  700 
of  conjunctiva,  584 
constitutional,  468 
of  cord,  662 
of  cornea,  586 

treatment  of,  587 
of  corpora  cavernosa,  652 
course  of,  463 
of  cranial  bones,  661 
curability  of,  471 
in  dentistry,  497 
development  of,  466 
diabetes  and,  476 

insipidus  and,  634 
diphtheria,  resemblance  to,  483 
direct  infection  in,  494 
of  dura  mater,  661 
of  ear,  595 

external,  595 
treatment  of,  596 

internal,  596 

treatment  of,  597 

middle,  595 

treatment  of,  596 
early,  vessel  changes  in,  496 
ephemeral  nephritis  and,  535 
of  epididymis,  late,  653 

diagnosis  of,  653 
exanthemata,  resemblance  to,  463 
of  eye,  584 

of  Fallopian  tubes,  653 
forms  of,  mild,  469 

severe,  460 
of  ganglia,  deep,  525 

lymphatic,  525 

superficial,  525 
and  gangrenous  ulcers,  659 
gout  and,  476 
of  hair,  578 

forms  of,  578 
of  heart,  626 

symptoms  of,  629 

treatment  of,  829 


Syphilis,  hereditary,  464 
alopecia  and,  722 
of  bones,  723 
Colles'  law  and,  707 

von  During  on,  707 
course  of,  702 

deformities  of  teeth  in,  726 
development  of,  7u8 
eruptions  of,  708 
furuncular,  711 
gummata  of  mouth  in,  714 
of  hair,  722 
hemorrhage  and,  722 
of  kidney,  715 
of  larynx,  715 
of  liver,  716 
of  lungs,  715 
of  lymphatic  ganglia,  723 
of  mucous  membranes,  712 

patches,  buccal,  in,  713 
of  nervous  system,  727 
of  onychia,  721 
osteochondritis  and,  723 
of  pancreas,  717 
periostitis  and,  725 
severity  of,  700 
source  of  infection  in,  704 
by  father,  704 
by  mother,  705 
of  spleen,  717 
of  suprarenal  capsules,  718 
symptoms  of,  700 
of  synovial  sheaths,  721 
of  testis,  719 
diagnosis  of,  719 
treatment  of,  721 
through  utero-placental  circulation,  706- 
of  thymus  gland,  722 
treatment  of,  727 

with   baths   of   corrosive   sublimate,. 

730 
with  calomel,  728 
general,  727 
with  gray  powder,  300 
with   hypodermic  injections  of   cor- 
rosive sublimate,  730 
with  iodide  of  potassium,  729 
with  local  applications,  730 
with  mercurial  inunctions,  731 
mixed,  729 
preventive,  bv  medication  of  father, 

731 
with  proto-iodide  of  mercury,  729 
with  Van  Swieten's  liquid,  729 
of  umbilical  vein,  716 
histology  of,  491 
hyperplasia  of  spleen  and,  534 
hysteria  in,  530 
ignored,  480 

in  ill-nourished  subjects,  472 
immunity  to,  478 

of  animals  to,  484 
incubation  of,  first  period,  466 
length  of  time  of,  467 
second  period,  467 
in  indigent  subjects,  472 
infantile,  709 


INDEX. 


751 


Syphilis,  infections  in,  blood,  494 
median,  497 
by  primary  lesion,  494 
by  secondary  lesion,  494 
vehicles  of,  494 
initial  lesion  of,  499 
appearance  of,  500 
condition  of  density  of,  499 
multiple,  500 
solitary,  499 
of  innocents,  499 
insontium,  465 
of  intestines,  632 
of  iris,  588 
jaundice  and,  534 
Justus'  test  in,  481 
of  kidney,  Beer  on,  634 

Wagner  on,  634 
of  lachrymal  apparatus,  581 
of  larynx,  624 
late,  of  kidney,  634 
of  lids,  630 
of  liver,  630 

date  of  onset,  630 
diagnosis  of,  630 
forms  of,  630 
prognosis  of,  631 
symptoms  of,  629 
of  lungs,  621 
malaria  and,  476 
malignant,  474 
micro-organism  of,  482 
modes  of  infection  of,  496 
bites,  496 
chancre  of  anus,  496 

of  nipples,  496 
circumcision,  ritual,  497 
coitus  ab  ore,  497 
communion  cup,  498 
contact,  direct,  496 
finger  chancre,  497 
kissing,  496 
mediate,  497 
mouth  lesions,  468 
sexual  act,  496 
skin-grafting,  497 
tattooing,  497 
unnatural  habits,  496 
vaccination,  497 
vaginal  examination,  495 
morphology  of,  488 
of  motor  nerves  of  eye,  593 

treatment  of,  594 
of  muscles,  637 
of  nails,  578 

diagnosis  of,  582 
prognosis  of,  582 
treatment  of,  583 
of  nervous  system,  660 

predisposing  causes,  660 
neuroglia  in,  493 
of  nose,  569 

treatment  of,  509 
of  oesophagus,  625 
in  old  age,  476 
of  optic  nerve,  592 
treatment  of,  593 


Syphilis  of  orbit,  584 
of  ovaries,  653 
pathology  of,  general,  488 
pharynx,  622 

diagnosis  of,  623 

symptoms  of,  622 
of  placenta,  708 
pleurisy  and,  533 

precocious  osseous  affections  and,  532 
primary,  522 
prognosis  of,  468 
pseudo-chancre  indure  and,  517 
Raynaud's  disease  and,  659 
of  rectum,  632 

forms  of,  633 
in  reddish  hair  subjects,  472 
reflex  disturbance  in,  531 
re-infection  with,  485 
of  retina,  590 
rheumatism  and,  476 
rheumatoid  pain  and,  533 
of  sclera,  586 

treatment  of,  586 
second  attack  of,  485 
secondary,  527 

albuminuria  in,  535 

analgesia  in,  531 

angina  pectoris  in,  534 

cachexia,  528 

cicatrices  in,  peculiarities  of,  539 

color  of  skin,  537 

enlargement  of  spleen  in,  534 

ephemeral  nephritis  in,  535 

eruptions  of,  localization  of,  538 

erysipelas  in,  538 

evolution  of,  unusual,  538 

fever  in,  536 

hemorrhage  in,  535 

herpes  zoster  in,  539 

hysteria  in,  530 

inflammation  of  pharynx  in,  533 
of  tonsils  in,  533 

insomnia  in,  528 

intercurrent  diseases  in,  505 

itching,  absence  of,  537 

jaundice  in,  534 

neuralgia  in,  528 

pain,  absence  of,  532 

pigmentation  in,  537 

polymorphism  in,  537 

precocious  osseous  affections  in,  532 

reflex  disturbances  in.  531 

rheumatism  in,  532 
acute  articular,  533 

rheumatoid  pains  in,  532 

symptoms  of,  527 

synovitis  in,  531 

typhoidal  condition  of,  529 

ulcers  in,  peculiarities  of,  539 
secretions  of,  infectious,  494 

non-infectious,  495 
of  spleen,  631 

symptoms  of,  631 
stages  of,  465 
of  stomach,  631 
suicide  and,  479 
in  surgeons,  495 


752 


INDEX. 


Syphilis,  synovitis  and,  531 
of  tendinous  sheaths,  638 
of  tendons,  638 
tertiary,  475,  598 
of  brain,  600 

lesions  of,  599 
curability  of,  602 
development  of,  598 
diagnosis  of,  errors  in,  600 
etiology  of,  603 
forms  of,  599 
infectiousness  of,  494,  603 
of  larynx,  623 
nature  of,  599 
nervedesions  of,  600 
of  nerves,  600 
onset  of,  599 
pathology  of,  602 
of  pharynx,  622 
precocious,  599 
of  spinal  cord,  600 
lesions  of,  600 
type,  form  of,  599 
of  testis,  656 
diagnosis  of,  655 
treatment  of,  657 
of  tongue,  618 
of  trachea,  626 

symptoms  of,  626 
transmission  of,  to  second  generation,  700 

to  third  generation,  700 
treatment  of,  670 
with  blue  pill,  674 
with  calomel,  674 
drawbacks  in,  693 
enteritis  in,  695 
general,  677 

-considerations  of,  670 
gingivitis  in,  695 
hypodermic  injections  in,  689 

of  bichloride  of  mercury,  690 
of  calomel,  693 

of  insoluble  mercurial  salts,  693 
local  effects  of,  693 
methods  used  in,  682 
technic  of,  690 
into  veins,  693 
inflammation  of  mouth  in,  693 

of  nasopharynx  in,  693 
initial  course,  675 
inunction,  683 
with  iodide  of  potassium,  676 

of  rubidium,  699 
with  iron  and  quinine,  676 
mercurial  cachexia  in,  696 
fumigations  in,  687 
direction  for,  687 
methods  employed,  688 
methodical,  670 
mixed,  679 

with  proto-iodide  of  mercury,  675 
salivation  in,  694 
with  saponaria,  681 
with  sarsaparilia,  681 
stomatitis  in,  694 
with  tannate  of  mercury,  676 
thermal  baths  in,  693 


Syphilis,  treatment  of,  thermal  springs  in, 
693 

with  thymo-acetate  of  mercury,  676 

toxic  effects  of  iodides  in,  697 

with  Zittman's  decoction,  681 
tuberculosis  and,  475 
typhoid  conditions  and,  529 
unmerited,  465 
of  uterus,  652 
of  vagina,  653 
in  women,  472 
Syphilitic  adenitis,  523 

diagnosis  of,  524 

treatment  of,  524 
alopecia,  573 

diagnosis  of,  577 

prognosis  of,  577 

treatment  of,  577 
aneurysm,  658 
aphasia,  667 

prognosis  of,  667 
atrophy  of  tongue,  620 
balanitis,  infecting,  504 
cachexia.  528 
caries  of  larynx,  625 
chorea,  668 
dactylitis,  647 

diagnosis  of,  650 

hereditary,  725 
treatment  of,  725 

prognosis  of,  651 

treatment  of,  651 
degeneration  of  vessels,  658 

gangrene  from,  659 
dementia,  668 
endocarditis,  628 
epilepsy,  665 

course  of,  665 

diagnosis  of,  666 

grand  mal,  665 

petit  mal,  665 
erythema  of  larynx,  569 

of  mouth,  566 

of  tongue,  643 
exostoses,  507 
gangrene  of  skin,  659 
glycosuria,  late,  634 
gumma  ta  of  larynx,  624 
headaches,  treatment  of,  669 
hemiplegia,  663 

prognosis  of,  664 
hepatitis,  diffuse,  628 

gummatous,  629 
induration  of  lymphatics,  525 
infants,  infection  from,  496 
infection  by  blood,  494 

by  hard  chancre,  494 

by  mucous  patches,  494 

pathology  of,  488 

by  tissue-elements  of  syphilis,  494 
inflammation,  interstitial,  of  spleen,  631 

of  larynx,  623 
leontiasis,  548 
lesions  of  kidney,  634 
locomotor  ataxia,  668 
lymphangitis,  522 

treatment  of,  522 


INDEX. 


753 


Syphilitic  lymphatics,  induration  of,  522 
mucous  membranes,  secretions  of,  infec- 
tiousness of,  494 
myocarditis.  628 
myositis,  637 
necrotic  nodule,  503 
onychia,  578 
orchitis,  656 
diagnosis  of,  657 
and  hydrocele,  diagnosis  of,  333 
treatment  of,  657 
osteomyelitis,  644 
osteoperiostitis,  644 
paraplegia,  666 
causes  of,  666 
prognosis  of,  667 
pericarditis,  629 
perichondritis  of  larynx,  624 
perionychia,  579 
phlebitis,  658 
proctitis,  633 
roseola,  539 
sclerosis  of  tongue,  618 
parenchymatous,  618 
superficial,  618 
separation  of  nails,  580 
stricture  of  rectum,  633 
synovitis,  late,  646 
prognosis  of,  647 
treatment  of,  647 
tumors  of  nervous  system,  663 
ulcerations  of  larynx,  624 
superficial,  569 
treatment  of,  570 
of  uterus,  hypertrophy  of,  662 
ulcus  elevatum,  502 
Syphilophobia,  479 

TATTOOING  and  syphilis,  497 
Teale's  gorget,  214 
Teeth,  deformities   of,   hereditary   syphilis 
and, 726 
Hutchinson's,  727 
Tendinous  sheaths,  syphilis  of,  638 
Tendons,  syphilis  of,  638 
Tertiary  syphilides,  604 
syphilis  of  brain,  600 
lesions  of,  598 
curability  of,  602 
development  of,  598 
diagnosis  of,  600 
errors  in,  600 
etiology  of,  603 
forms  of,  600 
of  ganglia,  625 
infectiousness  of,  603 
of  larynx,  624 
nature  of,  601 
nerve-lesions  in,  601 
onset  of,  599 
pathology  of,  599 
of  pharynx,  622 
precocious,  599 
of  spinal  cord,  600 
lesions  of,  599 
Testis,  abscess  of,  118 
atrophy  of,  353 

4S 


Testis,  atrophy  of,  epididymitis  and,  118 
carcinoma  of,  359 

treatment  of,  359 
cysts  of,  360 
enchondroma  of,  360 
fibroma  of,  359 

treatment  of,  359 
gangrene  of,  118 
gonorrhoea  1   neuralgia   of,   treatment   of, 

124 
hematocele  of,  343 
treatment  of,  343 
malplaced,  inflammation  of,  117 

symptoms  of,  117 
neuralgia  of,  epididymitis  and,  119 
sarcoma  of,  359 
cystic,  357 

treatment  of,  359 
strangulation  of,  torsion  of  cord  and,  346 

treatment  of,  346 
syphilis  of,  656 
hereditary,  719 
diagnosis  of,  719 
treatment  of,  721 
tuberculosis  of,  353 
treatment  of,  357 
undescended,    gonorrhoeal    inflammation 
of,  117 
Testicle,  swelled,  114 
onset  of,  115 

reflex  neuralgias  and,  119 
strapping  of,  124 
symptoms  of,  115 
Testicular  affections  and    hypertrophy   of 

prostate,  314 
Thionin  in  staining  gonococci,  23 
Thompson's  latest  stone-searcher,  379 

retention  catheter,  220 
Thornburgh's  suprapubic  operation  for  vari- 
cocele, 307 
Thymus  gland,  hereditary  syphilis  of,  722 
Tissues,  invasion  of,  by  gonococcus,  24 
Tongue,  chancre  of,  512 
gummata  of,  617 

diagnosis  of,  620 
superficial  syphilitic  affections  of,  567 

treatment  of,  568 
syphilis  of,  568 
syphilitic  atrophy  of,  620 
erythema  of,  568 
sclerosis  of,  617 

parenchymatous,  619 
superficial,  568 
Tonsil,  chancre  of,  513 

inflammation  of,    in   secondary    syphilis, 
533 
Tonsillitis,  epididymo-orchitis  from,  350 
Torsion  of  cord,  epididymitis  from,  346 
orchitis  and,  345 
strangulation  of  testis  from,  346 
Tour  de  Maitre,  197 
Trabeculation  of  bladder  and   hypertrophy 

of  prostate,  311 
Trachea,  syphilis  of,  626 

symptoms  of,  626 
Traumatic  pyelitis,  412 
pyelonephritis,   413 


754 


INDEX. 


Traumatic  stricture  of  urethra,  175 

treatment  of,  175 
Traumatisms  of  bladder,  393 
enlargement  of  penis  and,  265 
hematuria  and,  429 
of  kidney,  425 
of  prostate,  327 

causes  of,  327 

treatment  of,  327 
of  ureters,  398 
Treatment,  abortive,  of  acute  gonorrhoea,  56 
of  abscess  of  Bartholin's  glands,  70 

of  Cowper's  glands,  144 

of  prostate,  102 
of  bacteriuria,  430 
of  balanitis,  247 
of  buboes,  459 

abortive,  460 
of  calculi  of  prostate,  326 
of  cancer  of  penis,  280 
of  carcinoma  of  testis,  359 
of  condylomata  lata  of  anus,  572 
of  chancre,  518 
of  chancroidal  buboes,  462 

lymphangitis,  522 

paraphimosis,  459 

phimosis,  456 

by  dorsal  incision,  456 

failure  of,  457 
by  lateral  incision,  458 
of  chancroids,  451 
of  condylomata  lata  of  vulva,  572 
of  congestion  of  prostate,  100 
of  contusion  of  kidney,  424 
of  curvature  of  penis,  263 
of  cystitis,  374.. 
of  cvsts  of  kidney,  423 

.hydatid,  423 
of  dactylitis  syphilitica,  651 
of  dermoid  cysts  of  testis,  360 
of  dislocation  of  penis,  264 
of  elephantiasis  of  penis,  259 

of  scrotum,  259 
of  emphysema  of  scrotum,  284 
of  enuresis,  431 
of  epididymitis,  121 

chronic,  352 
of  epididymo-orchitis,  121 

from  muscular  contraction,  349 

from  urethral  operations,  348 
of  epispadias,  283 
of  erythematous  syphilide,  644 
of  exstrophy  of  bladder,  393 
of  extravasation  of  urine,  224 
of  fibroid  sclerosis  of  corpora  cavernosa, 

268 
of  fibroma  of  testis,  360 
of  floating  kidney,  423 
of  folliculitis,  in  female,  170 
of  foreign  bodies  in  bladder,  395 
of  fracture  of  penis,  262 
of  gangrene  of  penis,  275 

of  scrotum,  285 
of  gonorrhoea,  acute,  57 
posterior,  48 

in  boys,  54 

chronic  anterior,  83 


Treatment  of  gonorrhoea,  chronic  posterior, 
84 

in  female,  166 
urethra,  167 

of  rectum,  96 

of  uterine  cavity,  169 

of  vagina,  168 

of  vulva,  167 
of  gonorrhoeal  cardiac  affections,  133 

cystitis,  107 

folliculitis  in  women,  170 

neuralgia  of  testis,  124 

ophthalmia,  146 

peritonitis  in  male,  132 

rheumatism,  130 

serovascular  conjunctivitis,  148 

vaginalitis,  122 
of  gummata,  late,  609 
of  haematocele  of  epididymis,  344 

of  spermatic  cord,  diffuse,  345 
encysted,  345 

of  testis,  344 

of  tunica  vaginalis  testis,  343 
of  hsematuria,  429 
of  herpes  progenitalis,  252 
of  horny  growths  of  penis,  259 
of  hydrocele,  335 

encysted,  341 

of  hernial  sac,  343 

by  injections,  336 

of  spermatic  cord,  342 
diffuse,  339 
encysted,  339 

by  tapping,  335 
of  hydronephrosis,  620 
of  hypertrophy  of  prostate,  316 
of  hypospadias,  282 
of  incontinence  of  urine,  431 

in  children,  431 
of  juxta-urethral  sinuses,  136 
of  malignant  growths  of  prostate,  326 

precocious  syphilides,  560 
of  movable  kidney,  423 
of  nephritis,  suppurative,  415 
of  oedema  of  scrotum,  284 
of  onychia,  583 

operative,  of  hypertrophy  of  prostate,  318 
of  orchitis,  chronic,  352 
of  ossification  of  penis,  264 
palliative,  of    hvpertrophy    of    prostate, 

316 
of  paraphimosis,  240 

chronic,  240 
of  perinephritic  abscess,  417 
of  perinephritis,  417 
of  phimosis,  234 
of  pigmentary  syphilide,  565 
of  precocious  gummata,  563 
of  preputial  calculi,  265 
of  priapism,  273 
of  prostatitis,  chronic,  303 
of  pyelitis,  414 
of  pyelonephritis,  415 

tuberculous,  415 
of  pyonephrosis,  419 
of  retention  of  urine  in  hypertrophy  of 

prostate,  322 


INDEX. 


755 


Treatment  of  rupia,  617 
of  rupture  of  bladder,  393 
of  sarcoma  of  penis,  282 

of  testis,  359 
cystic,  359 
of  seminal  vesiculitis,  113 
of  spermatocystitis,  113 
of  stone  in  kidney,  421 
of  stricture  of  large  calibre,  203 

of  meatus,  199 

of  pendulous  urethra,  201 

at  penoscrotal  angle,  200 

of  urethra,  anterior,  202 
congenital,  175 
in  female,  228 
traumatic,  175 
of  suppurative  nephritis,  415 
of  syphilide,  bullous,  617 

impetigoform,  555 

papular,  large  flat,  549 

serpiginous,  615 

tubercular,  612 
of  syphilis,  H70 

of  cornea,  587 

of  ear,  external,  598 
internal,  597 
middle,  596 

of  heart,  629 

hereditary,  700 

of  motor  nerves  of  eye,  594 

of  nails,  683 

of  nervous  system,  669 

of  nose,  569 

of  optic  nerve,  593 

of  sclera,  586 

of  testis,  657 
of    syphilitic    affections,   superficial,   of 
tongue,  568 

adenitis,  524 

alopecia,  577 

choroiditis,  591 

dactylitis,  hereditary,  725 

headaches,  669 

lymphangitis,  521 

orchitis,  657 

superficial  ulceration  of  larynx,  570 

synovitis,  late,  647 
of  torsion  of  cord  and  strangulation   of 

testis,  345 
of  traumatism  of  prostate,  327 
of  tuberculosis  of  bladder,  389 

of  prostate,  325 

of  seminal  vesicles,  369 

of  testis,  357 
of  tumors  of  bladder,  388 

by  suprapubic  cystotomy,  387 

of  kidney,  422 

of  scrotum,  285 
benign,  285 
malignant,  285 
of  urethral  calculi,  286 

fever,  227 
of  urethritis,  catarrhal,  in  boys,  54 

membranous,  55 

posterior,  acute,  68 
of  urethrocystitis,  104 
of  urinary  infection,  227 


Treatment  of  varicocele,  364 
of  vegetations,  256 
of  vesical  calculi,  380 
by  litholapaxy,  381 
by  lithotomy,"  lateral,  384 
median,  385 
perineal,  384 
suprapubic,  385 
by  lithotrity,  3S0 
tumors,  388 
of  vulvovaginitis  in  young  girls,  170 
of  wounds  of  kidney,  425 
Tripper  faden,  33 
Tumors  of  bladder,  386 
cystoscopy  in,  391 
mixed,  386 
treatment  of,  389 
by  suprapubic  cystotomy,  389 
erectile,  of  penis,  256 
fatty,  of  penis,  261 
gummatous,  of  muscles,  638 
of  kidney,  422 
symptoms  of,  422 
treatment  of,  422 
varieties  of,  422 
pedunculated,  and  hypertrophy  of  pros- 
tate, 308 
of  prostate,  fibromyomatous,  308 

glandular,  308 
of  scrotum,  benign,  285 
treatment  of,  285 
malignant,  285 
treatment  of,  285 
sebaceous,  of  penis,  260 
sessile,  hypertrophy  of  prostate  and,  308 
syphilitic,  of  nervous  system,  663 
vesical,  386 
adenoma,  386 
benign,  386 
carcinoma,  386 
cystic,  386 
diagnosis  of,  388 
fibroma,  386 
malignant,  386 
mixed,  386 
myxoma,  386 
papillomatous,  386 
symptoms  of,  387 
treatment  of,  388 
villous,  386 
Tubercular  cystitis,  371-390 
syphilide,  612 
annular,  612 
course  of,  611 
diagnosis  of,  611 
hereditary,  712 
papillomatous,  611 
treatment  of,  612 
vegetating,  61 1 
Tuberculosis  of  bladder,  389 
diagnosis  of,  390 
symptoms  of,  389 
treatment  of,  391 
cystoscopy  in,  391 
of  prostate,  324 
svmptoms  of,  325 
treatment  of,  326 


756 


INDEX. 


Tuberculosis,  renal,  409 
symptoms  of,  409 
of  seminal  vesicles,  368 

treatment  of,  369 
syphilis  and,  475 
of  testis,  353 

treatment  of,  357 
Tuberculous  pyelitis,  409 
pyelonephritis,  409 
treatment  of,  415 
Tunica  vaginalis,  gonorrhceal  inflammation 
of.  114 
testis,  hsematocele  of,  acute,  343 
diagnosis  of,  343 
treatment  of,  344 
chronic,  343 
hydrocele  of,  328 
acquired,  329 
congenital,  328 
diagnosis  of,  328 
inversion  of,  for  hydrocele,  338 
Two-glass  test  in  gonorrhoea,  43 
Typhoid  fever,  epididymo-orchitis  from,  350 
syphilis  and,  529 

ULCEK,  gangrenous,  syphilis  and,  659 
gummatous,  606 
hereditary,  712 
Ulcerations,  superficial,  of  larynx,  570 
treatment  of,  570 
syphilitic,  of  larynx,  623 

of  uterus,  hypertrophy  of,  652 
Ulcerative  perionychia,  579 
Ulcus  elevatum  in  women,  515 
Umbilicated  chancre,  503 
Ureteritis,  398 
Ureters,  affections  of,  396 
calculi  in,  396 
catheterization  of,  400 
examination  of,  by  cystoscope,  400 
haematuria,  427 
inflammation'  of,  398 
shape  of,  395 
stone  in,  398 

kidney-colic  and,  398 
stricture  of,  398 
traumatisms  of,  398 
Urethra,  affections  of,  286 

anterior,  haematuria  from,  427 

lavage  of,  66 
calibre  of,  173 
chancre  of,  508 
deep,  haematuria  from,  427 
English  scale  for,  186 
exploration  of,  185 
female,  gonorrhoea  of,  149 

treatment  of,  167 
follicles  of,  abscess  of,  138 
foreign  bodies  in,  286 
symptoms  of,  287 
French  scale  for,  185 
instrumental  explorations  of,  185 
invasion  of  whole,  47 
prostatic,  inflammation  of,  288 
stricture  of,  172 

of  anterior,  treatment  of,  205 
causes  of,  174 


Urethra,  stricture  of,  complications  of,  182 
congenital,  174 
causes  of,  174 
treatment  of,  175 
course  of,  179 
development  of,  179 
electrolysis  in,'  217 
in  female,  228 
diagnosis  of,  228 
treatment  of,  228 
gonorrhceal,  pathology  of,  176 
inflammatory,  184 
instrumental  examination,  190,  193 
methods  of  examination,  191 
operation  of  divulsion  in,  217 
rapid  dilatation  for,  209 
retention  of  urine  in,  219 

aspiration  for,  220 
rupture  of,  by  operation,  217 
seat  of,  173 
spasmodic,  185 
symptoms  of,  179 
traumatic,  175 

treatment  of,  175 
varieties  of,  184 
Urethral  calculi,  286 
diagnosis  of,  286 
treatment  of,  286 
catheterization,  197 
fever,  225 
acute,  226 
causes  of,  226 
forms  of,  226 
treatment  of,  227 
glands,  Skene's,  inflammation  of,  159 
instrumentation,  shock  from,  227 
meter,  190 
operations,  epididymo-orchitis  from,  347 

treatment  of,  348 
prostatotomy,  319 
sounds,  186 
Urethrectomy,  219 
Urethritis,  bulbous,  chronic,  73 
catarrhal,  in  boys,  53 
course  of,  53 
symptoms  of,  53 
treatment  of,  54 
chronic,  endoscope  in,  89 
follicular,  88 
infectiousness  of,  92 
pathology  of,  77 
in  pendulous  urethra,  87 
at  penoscrotal  angle,  87 
prostatitis  and,  75 
symptoms  of,  76 
external,  133 
follicular,  chronic,  74 
gonorrhceal,  in  boys,  54 
complications  of,  54 
etiology  of,  54 
symptoms  of,  54 
treatment  of,  54 
membranous,  55 

treatment  of,  55 
posterior,  acute,  albuminuria  in,  52 
diagnosis  of,  53 
duration  of,  52 


INDEX. 


757 


Urethritis,  posterior,  acute,  incontinence  in, 
50 
prognosis  of,  53 
treatment  of,  68 
chronic,  88 
secretion  of,  52 
Urethrocystitis,  102 
acute,  103 
chronic,  104 
subacute,  104 
treatment  of,  104 
Urethrotome,  Civiale's,  191 
Maisonneuve-Fliihrer's,  190 
Otis,  192 
Urethrotomy,  external,  212 
without  guide,  215,  217 
internal,  209 

with  a  guide,  212 
Urinary    affections    and    hypertrophy    of 
prostate,  313 
fever,  225 
infection,  225 
causes  of,  225 
forms  of,  225 
symptoms  of,  226 
treatment  of,  227 
Urine,    changes    in,   and    hypertrophy    of 
prostate,  314 
examination  of,  in  gonorrhoea,  45 
extravasation  of,  222 
symptoms  of,  223 
treatment  of,  224 
incontinence  of,  430 
in  children,  431 
treatment  of,  431 
residual,    and    hypertrophy   of  prostate, 

311 
retention  of,  and  hypertrophy  of  prostate, 
343,  322 
treatment  of,  322 
from  stricture,  219 
aspiration  for,  220 
separator,  Cathelin's,  403 
Uterine  cavity,  gonorrhoea  of,  treatment  of, 

169 
Uteroplacental  circulation   and   hereditary 

syphilis,  706 
Uterus,  gonorrhoea  of,  151 
syphilis  of,  653 
syphilitic  ulcerative  hypertrophy  of,  652 

VACCINATION  and  syphilis,  497 
Vagina,  chancre  of,  516 
chancroids  of,  445 
gonorrhoea  of,  155 

treatment  of,  168 
syphilis  of,  516 
Vaginitis,  156 
gonorrhoeal,  155 

treatment  of,  168 
simple,  in  young  girls,  157 
Varicocele,  362 

ablation  of  scrotum  for,  367 
diagnosis  of,  364 
electrothermic  angiotribe  in,  366 
etiology  of,  382 
subcutaneous  ligation  in,  366 


Varicocele,  suprapubic  operation  of  Thorn- 
burgh  for,  367 
symptoms  of,  363 
treatment  of,  364 
varieties  of,  363 
Variolaform  syphilide,  555 

prognosis  of,  556 
Varix  of  penis,  260 
Vas  deferens,  inflammation  of,  114 
Vasectomy  and  hypertrophy  of  prostate,  321 
Vegetating  tubercular  syphilide,  611 
Vegetations,  corneous,  255 
diagnosis  of,  256 
of  penis,  254 

soft,  253 
in  pregnant  women,  255 
prognosis  of,  256 
treatment  of,  256 
Vein,  umbilical,  hereditary  syphilis  of,  722 
Venereal  warts,  253 

Verumontanum,  chronic   inflammation   of, 
288 
prognosis  of,  290 
symptoms  of,  289 
treatment  of,  291 
Vesical  calculi,  376 
diagnosis  of,  379 
symptoms  of,  378 
treatment  of,  380 
by  litholapaxy,  381 
by  lithotomy,  lateral,  384 
median,  385 
perineal,  384 
suprapubic,  385 
by  lithot'rity,  380 
tumors,  386 

diagnosis  of,  388 
symptoms  of.  387 
treatment  of,  388 
Vesicular  syphilide,  hereditary,  676 
Vessels,  syphilitic  degeneration  of,  658 

gangrene  from,  659 
Vestibulovaginal   glands,  inflammation   of, 

160 
Virulent  buboes,  447 

Voelcker  and  Joseph  on  diagnosis  of  kid- 
ney condition  without  catheterization  of 
ureters,  400 
Volkmann's  operation  for  hydrocele,  337 
v.  Bergmann's  operation  for  hydrocele,  337 
v.  VVald,  new  stain  in  chronic  gonorrhoea, 

23 
Vulva,  condylomata  lata  of,  571 
treatment  of,  571 
gonorrhoea  of,  158 
Vulva,  gonorrhoea  of,  treatment  of,  167 

vegetations  of,  and  pregnancy,  257 
Vulvitis,  simple,  163 
Vulvovaginitis  in  young  girls,  166 
treatment  of,  170 

WARTS,  venerea],  253 
Wheelhouse's  operation  for  stricture 
of  the  urethra,  215 
staff,  215 
Whooping-cough,  epididymo-orchitis  from, 
350 


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CORNIL  (V.).  SYPHILIS:  ITS  MORBID  ANATOMY,  DIAGNOSIS  AND 
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CROOK  (JAMES  K.).     MINERAL  WATERS  OF  UNITED  STATES.     Octavo, 

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CULBRETH  ( DAVID  M.  R. ) .    M A  TERIA  MEDIC  A  AND  PHARMA  COL  OGY. 

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DALTON  (JOHN  C).  A  TREATISE  ON  HUMAN  PHYSIOLOGY.  Seventh 
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DRUITT  (ROBERT).  THE  PRINCIPLES  AND  PRACTICE  OF  MODERN 
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DUANE  (ALEXANDER).  A  DICTIONARY  OF  MEDICINE  AND  THE 
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are  colored.     Cloth,  $4.50,  net;  leather,  $5.50,  net;  half  morocco,  $6.00,  net. 

JACKSON  ( GEORGE  THOMAS ) .    THE  READY-REFERENCE  HANDB 0 OK 

OF  DISEASES  OF  THE  SKIN.     Fourth   edition.     12mo.    volume  of    617   pages, 
with  82  engravings,  and  3  colored  plates.    Cloth,  $2.75,  net. 

JAMIESON  (W.  ALLAN).  DISEASES  OF  THE  SKIN.  Third  edition.  Octavo, 
656  pages,  with  1  engraving  and  9  double-page  chromo-lithographic  plates.     Cloth,  $6. 

JEWETT  (CHARLES).  ESSENTIALS  OF  OBSTETRICS.  Second  edition. 
12mo.,  385  pages,  with  80  engravings  and  5  colored  plates.     Cloth,     $2.25,  net. 

THE  PRACTICE  OF  OBSTETRICS.     By  American  Authors.    Second  edition. 

One    octavo  volume  of  775  pages,   with   445  engravings  in  black   and  colors,  and   35 
full-page  colored  plates.     Cloth,    $5.00;  leather,  $6.00;  half  morocco,  $6.50. 

JULER  (HENRY).  A  HANDBOOK  OF  OPHTHALMIC  SCIENCE  AND 
PRACTICE.  Third  edition.  Octavo,  733  pages,  with  190  engravings,  25  plates,  Test- 
types  and  Color-Blindness  Test.     Cloth,  $5.25,  net. 

KELLY  (A.O.J.)  A  MANUAL  OF  THE  PRACTICE  OF  MEDICINE. 
Octavo,  about  600  pages,  illustiated.     Preparing. 

KIEPE  (EDWARD  J.).  EPITOME  OF  MATERIA  MEDICA  AND  THERA- 
PEUTICS.    Lea's  Series  of  Medical  Epitomes.     See  page  10. 

KING  (A.  F.  A.).  A  MANUAL  OF  OBSTETRICS.  Ninth  edition.  In  one 
12mo.  volume  of  629  pages,  with  275  illustrations.     Cloth,  $2.50,  net. 

KIRK  (EDWARD  C).  OPERATIVE  DENTISTRY.  Second  edition.  See 
American  Text-books  of  Dentistry,  page  2. 

KLEIN  (E.).     ELEMENTS  OF  HISTOLOGY.     Fifth  edition.     In  one  pocket-size 

12mo.   volume  of  506  pages,  with  296  engravings.     Cloth,  $2.00,  net.     Students'  Series  of 
Manuals.     Page  15. 

KOPLIK  ( HENRY ) .  DISEA  SES  OF  INF  A  NCY  AND  CHILDHO  OD.  Octavo, 
675  pages  with  169  engravings  and  32  plates  in  black  and  colors.  Cloth,  $5.00  ;  leather, 
$6.00,  net. 

Philadelphia,  706,  708  and  710  Sansom  St.— New  York,  111  Fifth  Avenue. 


10  LEA    BROTHERS    &     CO.'S    PUBLICATIONS. 


LANDIS  (HENRY  G.).  THE  MANAGEMENT  OF  LAB  OB.  In  one  handsome 
12mo.  volume  of  329  pages,  with  28  illustrations.     Cloth,  $1.75. 

LEA  (HENRY  C).  CHAPTEBS  FBOM  THE  BELIGIOUS  HISTOBY  OF 
SPAIN;  CENSOBSHIP  OF  THE  PBESS ;  MYSTICS  AND  ILLUMINATI ; 
THE  ENDEMONIADAS ;  EL  SANTO  NINO  BE  LA  GUABBIA;  BBI- 
ANDA  BE  BABBAXI.    In  one  12mo.  volume  of  522  pages.     Cloth  $2.50. 


A  HISTOBY  OF  AUBIOULAB  CONFESSION  ANB  INBULGENCES 

IN  THE  LATIN  CHUBCH.     In  three  octavo  volumes  of  about  500  pages  each. 
Per  volume,  cloth,  $3. 

THE  MOBISCOS  OF  SPAIN:  THEIB  CONVEBSION  ANB  EXPULSION. 


In  one  royal  12mo.  volume  of  about  425  pages.     Extra  cloth,  $2.25,  net. 

STUBIES   IN  CHUBCH  HISTOBY.      New    edition.      12mo  ,    605  pages. 

Cloth,  $2.50. 

SUPEBSTITION  ANB  FOBCE ;  ESSAYS  ON  THE  WAGEB  OF  LAW, 

THE    WAGEB    OF  BATTLE,   THE   OBBEAL   ANB    TOBTUBE.     Fourth 
edition,  thoroughly  revised.     In  one  royal  12mo.  volume  of  629  pages.     Cloth,  $2.75. 

LEA'S  SERIES  OF  MEDICAL  EPITOMES.  Edited  by  V.  C.  Pedersen,  M.D. 
Covering  the  entire  held  of  medicine  and  surgery  in  twenty  two  convenient  volumes  of 
about  250  pages  each,  amply  illustrated  and  written  by  prominent  teachers  and  specialists. 
Compendious,  authoritative  and  modern.  Following  each  chapter  is  a  series  of  questions 
which  will  be  found  convenient  in  quizzing.     The  Series  is  constituted  as  follows  : 

Hale's  Anatomy.  Guenther's  Physiology.  McGlannan's  Inorganic  Chemistry  and 
Physics.  McGlannan's  Organic  and  Physiological  Chemistry.  Kiepe's  Materia  Medica 
and  Therapeutics.  Dayton's  Practice  of  Medicine.  Hollis's  Medical  Diagnosis.  Arneill's 
Clinical  Diagnosis  and  Urinalysis.  Nagel's  Nervous  and  Mental  Diseases.  Wathen's 
Histology.  Stenhouse's  Pathology.  Archinard's  Bacteriology  and  Microscopy.  Magee 
and  Johnson's  Surgery.  Ailing  and  Griffen  on  the  Eye  and  Ear.  Ferguson  on  the  Nose 
and  Throat.  Schmidt's  Genito- Urinary  and  Venereal  Diseases.  Schalek's  Dermatology. 
Pedersen  and  Parker's  Gynaecology.  Manton's  Obstetrics.  Tuley's  Pediatrics.  Dwight's 
Jurisprudence.  Dwight's  Toxicology.  For  separate  notices  see  under  various  authors' 
names.- 

LEA'S  SERIES  OF  POCKET  TEXT-BOOKS.    See  page  12. 

LE  FEVRE  (EGBERT).    A  TEXT-BOOK  OF  PHYSICAL  BIAGNOSIS.     12mo., 

450  pages,  74  engravings,  12  plates.     Cloth,  $2.25,  net. 

LONG  (ELI  H.).      BENTAL  MATEBIA  MEBICA    ANB   THEBAPEUTICS. 

12mo.,  321  pages,  6  engravings,  18  plates.     Cloth,  $3.00,  net. 

LOOMIS  (ALFRED  L.)  AND  THOMPSON  (W.  GILMAN),  Editors.  A  SYS- 
TEM OF  PBA  CTICAL  MEBICINE.  In  Contributions  by  Various  American  Authors. 
In  four  very  handsome  octavo  volumes  of  about  900  pages  each,  fully  illustrated  in  black 
and  colors.  Per  volume,  cloth,  $5 ;  leather,  $6 ;  half  Morocco,  $7.  For  sale  by  sub- 
scription only.     Full  prospectus  free  on   application. 

LYMAN  (HENRY  M.).  THE  PBACTICE  OF  MEBICINE.  In  one  very  hand- 
some  octavo  volume  of  925  pages  with  170  engravings.     Cloth,  $4.75 ;  leather,  $5.75. 

MAGEE  (M.  D.)  AND  JOHNSON  (WALLACE).  AN  EPITOME  OF  SUB- 
GEBY.  12mo.,  about  300  pages,  with  130  engravings.  Clotb,  $1.00,  net.  Led! s  Series 
of  Medical  Epitomes.     See  page  10. 

MAISCH  (JOHN  M.).  A  MANUAL  OF  OBGANIC  MATEBIA  MEBICA. 
Seventh  edition,  thoroughly  revised  by  H.  C.  C.  Maisch,  Ph.G.,  Ph.D.     In  one  12mo. 

of  512  pages,  with  285  engravings.     Cloth,  $2.50,  net. 

MALSBARY  (GEO.  E.).  A  POCKET  TEXT-BOOK  OF  THEOBY  ANB 
PBACTICE  OF  MEBICINE.  12mo.  405  pages,  with  45  illustrations.  Cloth,  $1.75, 
net;  flexible  red  leather,  $2.25,  net.     Lea's  Series  of  Pocket  Text-Books.     Page  12. 


Philadelphia,  706,  708  and  710  Sansom  St.— New  York,  111  Fifth  Avenue. 


LEA     BROTHERS    &     CO.' S    PUBLICATIONS.  11 

MANTON  (W.  P.).  AN  EPITOME  OF  OBSTETRICS.  12mo.,  265  pages,  82 
illustrations.     Cloth,  $1.00,  net.    ' Lea' s  Series  of  Medical  Epitomes.     See  page  10. 

MANUALS.     See  Medical  Epitomes,  page  10  ;  Pocket  Text-Books,  page  12. 

MARSH  (HOWARD).     DISEASES  OF  THE  JOINTS.    In  one  12mo.  volume  of 

468  pages,  with  64  engravings  and  a  colored  plate.     Cloth,  $2.     See  Series  of  Clinical 
Manuals,  page  13. 

MARTIN  (EDWARD.)  SURGICAL  DIAGNOSIS.  One  12mo.  volume  of  400 
pages,  richly  illustrated.     Preparing. 

MARTIN  (WALTON)  AND  ROCKWELL  (W.  H.,  JR.).  A  POCKET  TEXT- 
BOOK OF  CHEMISTRY  AND  PHYSICS.  12mo.  366  pages,  with  137  illus- 
trations. Cloth,  $1.50,  net;  flexible  leather,  $2.00,  net.  Lea's  Series  of  Pocket  Text- 
Books.     Page  12. 

McGLANNAN  (A.).  AN  EPITOME  OF  INORGANIC  CHEMISTRY  AND 
PHYSICS.  12mo,  216  pages,  with  20  engravings.  Cloth,  $1.00,  net.  Lea's  Series  of 
Medical  Epitomes.     See  page  10. 

AN  EPITOME  OF  ORGANIC  AND  PHYSIOLOGICAL  CHEMISTRY. 

12mo.,  246  pages,  with  9  engravings.    Cloth,  $1.00,  net.    Lea's  Series  of  Medical  Epitomes. 
See  page  10. 

MEDICAL  EPITOME  SERIES.     See  Lea's  Series  of  Medical  Epitomes,  page  10. 

MEDICAL  NEWS  POCKET  FORMULARY.    See  page  1.    $1.50,  net. 

MITCHELL  (JOHN  K.).  REMOTE  CONSEQUENCES  OF  INJURIES  OF 
NERVES  AND  THEIR  TREATMENT.  12mo.,  239  pages,  12  illustrations.  Cloth, 
$1.75. 

MITCHELL  (S.  WEIR).  CLINICAL  LESSONS  ON  NERVOUS  DISEASES. 
12mo.,  299  pages,  with  17  engravings  and  2  colored  plates.     Cloth,  $2.50. 

MORROW  (PRINCE  A.).  SOCIAL  DISEASES  AND  MARRIAGE.  SOCIAL 
PROPHYLAXIS.     Octavo,  390  pages.     Cloth,  $3.00,  net.     Just  ready. 

MUSSER  (JOHN  H.).  A  TREATISE  ON  MEDICAL  DIAGNOSIS,  for  Students 
and  Physicians.  New  (fifth)  edition,  thoroughly  revised  and  rewritten.  Octavo,  1205 
pages,  with  395  engravings,  and  63  full-page  colored  plates.  Cloth,  $6.50,  net;  leather, 
$7.50,  net;  half  morocco.  $8.00,  net. 

NAGEL  (J.  D.)  AN  EPITOME  OF  NERVOUS  AND  MENTAL  DISEASES. 
12mo.,  about  250  pages,  illustrated.  Shortly.  Lea's  Series  of  Medical  Epitomes.  See 
page  10. 

NATIONAL  DISPENSATORY.     See  Stille,  Maisch  &  Caspari,  page  14. 

NATIONAL    FORMULARY.      See  National  Dispensatory,  page  14. 

NATIONAL  MEDICAL  DICTIONARY.     See  Billings,  page  3. 

NETTLESHIP  (E.).  DISEASES  OF  THE  EYE.  Sixth  American  from  sixth 
English  edition.  Thoroughly  revised.  12mo.,  562  pages,  with  192  engravings,  5  colored 
plates,  Test-types,  Formulae  and  Color-blindness  Test.     Cloth,  $2.25,  net. 

NICHOLS  (JOHN  B.)  AND  VALE  (F.  P.).  A  POCKET  TEXT-BOOK  OF 
HISTOLOGY  AND  PATHOLOGY.  12mo.  of  459  pages,  with  213  illustrations. 
Cloth,  $1.75,-ne<;  flexible  leather,  $2.25,  net.    Lea's  Series  of  Pocket  Text-Books.    Page  12. 

NORRIS  (WM.  F.)  AND  OLIVER  (CHAS.  A.).  TEXT-BOOK  OF  OPHTHAL- 
MOLOGY. In  one  octavo  volume  of  641  pages,  with  357  engravings  and  5  colored 
plates.     Cloth,  $5 ;  leather,  $6. 

OWEN  (EDMUND).  SURGICAL  DISEASES  OF  CHILDREN.  In  one  12mo. 
volume  of  525  pages,  with  85  engravings  and  4  colored  plates.  Cloth,  $2.  See  Series  of 
Clinical  Manuals,  page  13. 

PARK  (WILLIAM  H. ) .    BA CTERIOL OGY  IN  MEDICINE  AND  SUR GER  Y. 

12mo.,  688  pages,  87  engravings  in  black  and  colors,  2  colored  plates.     Cloth,  $3.00,  net. 


Philadelphia,  706,  708  and  710  Sansom  St. — New  York,  111  Fifth  Avenue. 


12  LEA    BROTHERS    &     CO.'  S    PUBLICATIONS. 

PARK  (ROSWELL),  Editor.  A  TREATISE  ON  SURGERY,  by  American  Authors. 
For  Students  and  Practitioners  of  Surgery  and  Medicine.  Third  edition.  In  one 
large  octavo  volume  of  1408  pages,  with  692  engravings  and  64  plates.  Cloth,  $7.00; 
leather,  $8.00,  net.  Published  also  in  2  volumes:  Vol.  L,  General  Surgery  ;  Vol.  II., 
Special  or  Kegional  Surgery.     Per  volume,  cloth,  $3.75,  net;  leather,  $4.75,  net. 

PEDERSEN  AND  PARKER'S  EPITOME  OF  GYNECOLOGY.  Lea's  Series  of 
Medical  Epitomes.     See  page  10. 

PEPPER  (A.  J.).  SURGICAL  PATHOLOGY.  In  one  12mo.  volume  of  511  pages, 
with  81  engravings.     Cloth,  $2.     See  Students'  Series  of  Manuals,  page  15. 

PICK  (T.  PICKERING).  FRACTURES  AND  DISLOCATIONS.  In  one  12mo. 
volume  of  530  pages,  with  93  engravings.    Cloth,  $2.    See  Series  of  Clinical  Manuals,  p.  13. 

PLAYFAIR  (W.  S.).  THE  SCIENCE  AND  PRACTICE  OF  MIDWIFERY. 
Seventh  American  from  the  Ninth  English  edition.  Octavo,  700  pages,  with  207  engrav- 
ings and  7  full  page  plates.     Cloth,  $3.75/  leather,  $4.75,  net. 

POCKET  FORMULARY.     Fifth  edition.     See  page  1. 

POCKET  TEXT-BOOK  SERIES  covers  the  entire  domain  of  medicine  in  eighteen 
volumes  of  350  to  525  pages  each,  written  by  teachers  in  leading  American  medical  col- 
leges. Issued  under  the  editorial  supervision  of  Been  B.  Gallatjdet,  M.D. ,  of  the  College 
of  Physicians  and  Surgeons,  New  York.  Thoroughly  modern  and  authoritative,  concise 
and  clear,  amply  illustrated  with  engravings  and  plates,  handsomely  printed  and 
bound.  The  series  is  constituted  as  follows:  Rockwell's  Anatomy;  Collins  &  Bock- 
well's  Physiology;  Martin  &  Rockwell's  Chemistry  and  Physics;  Nichols  &  Vale's 
Histology  and  Pathology;  Schleif's  Materia  Medica  and  Therapeutics  ;  Malsbary's  Prac- 
tice; Collins  &  Davis'  Diagnosis;  Potts  on  Nervous  and  Mental  Diseases;  Gallaudet's 
Surgery  ;  Hayden  on  Venereal  Diseases ;  Grindon  on  the  Skin  ;  Ballenger  &  Wippern  on 
Eye,  Ear,  Nose  and  Throat ;  Evans'  Obstetrics  ;  Crockett's  Gynecology  ;  Tuttle  on  Dis- 
eases of  Children  ;  Zapffe's  Bacteriology;  Wicks  on  Nursing ;  Hamilton  on  Massage.  For 
separate  notices  see  under  various  authors'  names.     Special  circular  free  on  application. 

POLITZER  (ADAM).  A  TEXT-BOOK  OF  THE  DISEASES  OF  THE  EAR 
AND  ADJACENT  ORGANS.  Third  American  from  the  Fourth  German  edition. 
In  one  octavo  volume  of  896  pages,  with  346  engravings.     Cloth,  $7.50,  net. 

POSEY  (W.  C.)  AND  WRIGHT  (JONATHAN).  A  TREATISE  ON  THE 
EYE,  NOSE,  THROAT  AND  EAR.  Octavo,  1251  pages,  richly  illustrated  with 
650  engravings  and  35  plates  in  black  and  colors.  Cloth,  $7.00;  leather,  $8.00,  net. 
Published  also  in  two  volumes.  Vol.  I.,  Posey  on  the  Eye.  Cloth,  $4.00,  net.  Vol. 
II. ,  Wright  on  the  Nose,  Throat  and  Ear.     Cloth,  $3.50,  net. 

POTTS  (CHAS.  S.).  A  POCKET  TEXT-BOOK  OF  NERVOUS  AND 
MENTAL  DISEASES.  12mo.  of  455  pages,  with  88  illustrations.  Cloth,  $1.75,  net; 
flexible  leather,  $2.25,  net.     Lea's  Series  of  Pocket  Text-Books,  page  12. 

A    TEXT-BOOK   ON   MEDICINE  AND   SURGICAL  ELECTRICITY. 

Octavo,  about  350  pages,  amply  illustrated.     Shortly. 

PROGRESSIVE  MEDICINE.    See  page  1.    Per  annum,  $9.00,  in  cloth ;  $6.00  in  paper. 

PURDY  (CHARLES  W.).  BRIGHT'S  DISEASE  AND  ALLIED  AFFEC- 
TIONS OF  THE  KIDNEY.  In  one  octavo  volume  of  288  pages,  with  18  engrav- 
ings.    Cloth,  $2. 

PYE-SMITH  (PHILIP  H.).  DISEASES  OF  THE  SKIN.  In  one  12mo.  volume 
of  407  pages,  with  28  illustrations,  18  of  which  are  colored.     Cloth,  $2. 

RALFE  (CHARLES  H.).  CLINICAL  CHEMISTRY.  In  one  12mo.  volume  of 
314  pages,  with  16  engravings.     Cloth,  $1.50.     See  Students'  Series  of  Manuals,  page  14. 

REMSEN  (IRA).  THE  PRINCIPLES  OF  THEORETICAL  CHEMISTRY. 
Fifth  edition  thoroughly  revised.     In  one  12mo.  volume  of  326  pages.     Cloth,  $2. 

REYNOLDS  (EDWARD)  AND  NEWELL  (F.  B.\  MANUAL  OF  PRACTICAL 
OBSTETRICS.     Octavo,  531  pages,  253  engravings  and  3  plates.     Cloth,  $3.75,  net. 


Philadelphia,  706,  708  and  710  Sansom  St. — New  York,  111  Fifth  Avenue. 


LEA    BROTHERS    &     CO.'S    PUBLICATIONS.  13 

RICHARDSON  (MA.URICE  H.).  A  PRACTICAL  TREATISE  ON  ABDOMI- 
NAL SURGERY.  Octavo,  about  800  pages,  profusely  illustrated  with  engravings 
and  colored  plates.     Preparing. 

RICHARDSON   (BENJAMIN  WARD).    PREVENTIVE  MEDICINE.    In  one 

octavo  volume  of  729  pages.     Cloth,  $4. 

ROBERTS  (JOHN  B.).  THE  PRINCIPLES  AND  PRACTICE  OF  MODERN 
SURGERY.  Second  edition.  In  one  octavo  volume  of  838  pages,  with  474  engravings 
and  8  plates.     Cloth,  $4.25,  net;  leather,  $5.25,  net. 

ROBERTS  ( SIR  WILLIAM ) .  A  PR  A  CTICAL  TREA  TISE  ON  URINARY  AND 
RENAL  DISEASES,  INCLUDING  URINARY  DEPOSITS.  Fourth  American 
from  the  fourth  London  edition.     Octavo,  609  pages,  81  illustrations.     Cloth,  $3.50. 

ROCKWELL  (W.  H.,  Jr.).  A  POCKET  TEXT-BOOK  OF  ANATOMY.  12mo., 
600  pages,  illustrated.  Cloth,  $2.25;  flexible  leather,  $2.75,  net.  Lea's  Series  of  Pocket 
Text-Books.     Page  12. 

ROGER  (G.  H.).  INFECTIOUS  DISEASES.  Translated  by  M.  S.  Gabriel,  M.D. 
Octavo,  864  pages,  41  illustrations.     Cloth,  $5.75,  net.     Just  ready. 

ROSS  (JAMES).  THE  DISEASES  OF  THE  NERVOUS  SYSTEM.  Octavo, 
726  pages,  with  184  engravings.     Cloth,  $4.50;  leather,  $5.50. 

SCHAFER  (EDWARD  A.).  THE  ESSENTIALS  OF  HISTOLOG  Y,  DESCRIP- 
TIVE AND  PRACTICAL.  Sixth  edition.  Octavo,  426  pages,  with  463  illustra- 
tions.    Cloth,  $3,  net. 

A    COURSE    OF  PRACTICAL    HISTOLOGY.     Second  edition.     In    one 


12mo.  volume  of  307  pages,  with  59  engravings.     Cloth,  $2.25. 

SCHALEK  (ALFRED).  AN  EPITOME  OF  DERMATOLOGY.  12mo.,  225 
pages,  34  illustrations.     Cloth,  $1.00,  net.    Lea!  s  Series  of  Medical  Epitomes.    See  page  10. 

SCHLEIF  (WM.).  A  POCKET  TEXT-BOOK  OF  MATERIA  MEDIC  A, 
THERAPEUTICS,  PRESCRIPTION  WRITING,  MEDICAL  LATIN  AND 
MEDICAL  PHARMACY.  Second  edition.  12mo.,  380  pages.  Cloth,  $1.75; 
flexible  leather,  $2.25,  net.     Lea' s  Series  of  Pocket  Text-Books.     Page  12. 

SCHMAUS  (HANS.)  AND  EWING  (JAMES).  PATHOLOGY  AND  PATH- 
OLOGICAL ANATOMY.  Sixth  edition.  Octavo,  602  pages,  with  351  illustrations, 
including  34  colored  inset  plates.     Cloth,  $4.00,  net. 

SCHMIDT  (LOUIS  E.).  AN  EPITOME  OF  GENITO-URINARY AND  VENE- 
REAL DISEASES.  12mo,  249  pages,  21  illustrations.  Cloth,  $1.00,  net.  Lea's 
Series  of  Medical  Epitomes.     See  page  10. 

SCOTT  (R.  J.  E. ).     See  State  Board  License  Examination  Series.     Page  14. 

SENN  (NICHOLAS).  SURGICAL  BACTERIOLOGY.  Second  edition.  In  one 
octavo  volume  of  268  pages,  with  13  plates,  10  of  which  are  colored,  and  9  engravings. 
Cloth,  $2. 

SERIES  OF  CLINICAL  MANUALS.  A  Series  of  Authoritative  Monographs  on 
Important  Clinical  Subjects,  in  12mo.  volumes  of  about  550  pages,  well  illustrated.  The 
following  volumes  are  now  ready:  Carter  and  Frost's  Ophthalmic  Surgery,  $2. 25 ; 
Marsh  on  Diseases  of  the  Joints,  $2 ;  Owen  on  Surgical  Diseases  of  Children,  $2  ; 
Pick  on  Fractures  and  Dislocations,  $2.  For  separate  notices,  see  under  various 
authors'  names. 

SERIES  OF  MEDICAL  EPITOMES.    See  page  10. 

SERIES  OF  POCKET  TEXT-BOOKS.    See  page  12. 

SERIES  OF  STATE  BOARD  LICENSE  EXAMINATIONS.    See  page  14. 

SERIES  OF  STUDENTS'  MANUALS.    See  page  15. 

SIMON  (CHARLES  E.).  CLINICAL  DIAGNOSIS,  BY  MICROSCOPICAL 
AND  CHEMICAL  METHODS.  Fifth  edition,  thoroughly  revised.  Octavo,  695 
pages,  with  150  engravings  and  22  full-page  plates  in  colors.    Cloth,  $4.00,  net.     Just  ready. 

PHYSIOLOGICAL   CHEMISTRY.     In    one    octavo  volume    of   453    pages. 


Cloth,  $3.25,  net. 


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14  LEA    BROTHERS    &     CO.'S    PUBLICATIONS. 

SIMON  (W.).  MANUAL  OF  CHEMISTRY.  A  Guide  to  Lectures  and  Laboratory 
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SLADE  (D.  D.).  DIPHTHERIA  ;  ITS  NATURE  AND  TREATMENT.  Second 
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SMITH   (J.   LEWIS).     THE  DISEASES  OF  INFANCY  AND  CHILDHOOD. 

Eighth  edition,  thoroughly  revised  and  rewritten  and  greatly  enlarged.     8vo.,  983  pages, 
with  273  illustrations  and  4  full-page  plates.     Cloth,  $4.50  ;  leather,  $5.50. 

SMITH  (STEPHEN).  OPERATIVE  SURGERY.  Second  and  thoroughly  revised 
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SOLLY  (S.  EDWIN).  A  HANDBOOK  OF  MEDICAL  CLIMATOLOGY. 
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STARR  (M.  ALLEN).    A  TREATISE  ON  ORGANIC  NERVOUS  DISEASES. 

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STENHOUSE'S  EPITOME  OF  PATHOLOGY.  Lea's  Series  of  Medical  Epitomes. 
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STILLE  (ALFRED),  MAISCH  (JOHN  M.)  AND  CASPARI  (CHAS.  JR.). 
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STIMSON  (LEWIS  A.).  A  MANUAL  OF  OPERATIVE  SURGERY.  Fourth 
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TAIT  (LAWSON ,.  DISEASES  OF  WOMEN  AND  ABDOMINAL  SURGER  Y. 
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TAYLOR  (ALFRED  S.).  MEDICAL  JURISPRUDENCE.  From  the  twelfth 
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TAYLOR  (ROBERT  W.).  GENITO-URINARY  AND  VENEREAL  DIS- 
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TAYLOR  (SEYMOUR).  INDEX  OF  MEDICINE.  A  Manual  for  the  use  of  Senior 
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THOMAS  (T.  GAILLARD)  AND  MUNDE  (PAUL  F.).  A  PRACTICAL 
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THOMPSON  (W.  OILMAN).  A  TEXT-BOOK  OF  PRACTICAL  MEDICINE. 
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THOMPSON  (SIR  HENRY).  THE  PATHOLOGY  AND  TREATMENT  OF 
STRICTURE  OF  THE  URETHRA  AND  URINARY  FISTULA.  From  the 
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THORNTON'S  FORMULARY.      The  Medical  News  Pocket  Formulary.     See  page  1. 

TIRARD  (NESTOR).  MEDICAL  TREATMENT  OF  DISEASES  AND  SYMP- 
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TREVES  (SIR  FREDERICK).  OPERATIVE  SURGERY.  New  (second)  edition, 
revised  by  the  author  and  Jonathan  Hutchinson,  Jr.,  F.R.C.S.  In  two  8vo  volumes 
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TREVES  (FREDERICK).  A  SYSTEM  OF  SURGERY.  In  Contributions  by 
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SURGICAL   APPLIED   ANATOMY.    New  edition.      12mo.,  577  pages,  80 


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TUTTLE  (GEO.  M.).  A  POCKET  TEXT-BOOK  OF  DISEASES  OF 
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§2.00,  net.     Lea! s  Series  of  Pocket  Text-Books.     Page  12. 

VAUGHAN  (VICTOR  C.)  AND  NOVY  (FREDERICK  G.).  CELLULAR 
TOXINS,  or  the  Chemical  Factors  in  the  Causation  of  Disease.  New  (4th)  edition. 
12mo.,  480  pages  with  6  engravings.     Cloth,  $3,  net. 

VEASEY  (CLARENCE  A.).    A  MANUAL   OF  OPHTHALMOLOGY.    12mo., 

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WATSON  (THOMAS).  LECTURES  ON  THE  PRINCIPLES  AND  PRAC- 
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two  8vo.  volumns  of  1840  pages,  with  190  engravings.     Cloth,  §9. 

WHARTON  (HENRY  R.).     MINOR  SURGERY  AND  BANDAGING.     Fifth 

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WHITLA  (WILLIAM).  DICTIONARY  OF  TREATMENT.  Octavo  of  917 
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WHITMAN  (ROYAL).  ORTHOPEDIC  SURGERY.  Second  edition.  One  octavo 
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WICKS  MAUD  (A.).  A  POCKET  TEXT-BOOK  OF  NURSING.  12mo.,  about 
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WILLIAMS  (DAWSON).  MEDICAL  DISEASES  OF  INFANCY  AND 
CHILDHOOD.  Srcond  edition  specially  revised  for  America  by  F.  S.  Churchill, 
A.M.,  M.D.     Octavo,  53 i  pages,  52  engravings  and  2  colored  plates.      Cloth,  §3.50,  net. 

WILSON  (ERASMUS ) .  A  SYSTEM  OF  HUMAN  ANA  TO  MY.  Revised  edition, 
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WOOLSEY  (GEORGE).  APPLIED  SURGICAL  ANATOMY  REGIONALLY 
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